NCT02723019|CompletedResultsDMC
Mi Puente: My Bridge to Better Cardiometabolic Health and Well-Being
Mi Puente
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Sponsor study identifier
interventional
536
1 country
1
Study Start
July 14, 2016
Actual (reported)Primary Completion
November 30, 2020
Actual (reported)Study Completion
November 30, 2020
Actual (reported)Mi Puente (or "My Bridge") is a culturally-tailored, interdisciplinary approach designed to support at-risk Hispanic patients and their caregivers pre- and post-hospital discharge as they navigate the multi-level barriers that contribute to inequities in health care access and use, and in turn, perpetuate disparities in cardiometabolic and behavioral health. Mi Puente utilizes a sustainable nurse + volunteer peer team-based model, bridging partnership between inpatient and outpatient care settings to meet the integrated (i.e., physical and behavioral) health needs of Hispanics who are hospitalized with multiple chronic cardiometabolic conditions and one or more behavioral health concern(s). Participants will be tested at Scripps Mercy Hospital - a large, non-profit, safety net hospital located in the US/Mexico border region of South San Diego County, California. The proposed randomized controlled trial will test Mi Puente versus Usual Care (evidence-based, best practice discharge procedures) in improving hospital utilization, patient-reported, and cost effectiveness outcomes. Electronic medical records (EMR) will be used to identify eligible patients and examine primary outcomes.
Registry-reported information. Elapsed time and enrollment totals alone do not measure study progress or recruitment pace.
November 30, 2020
Actual (reported)Click on a node to explore related trials.
Some registry-reported names shown below are not yet linked in this graph.
Dates and qualifiers reported by the registry. Estimated dates do not confirm that a milestone has occurred.
December 1, 2015
Actual (reported)March 30, 2016
Actual (reported)July 14, 2016
Actual (reported)November 30, 2020
Actual (reported)November 30, 2020
Actual (reported)February 28, 2023
Actual (reported)Number of Patients With at Least 1 Hospital Readmission Within 30 Days After Enrollment
Number of patients with at least one hospital readmission within 30 days after enrollment
30 days from baseline
Number of Patients With at Least 1 Hospital Readmission Within 180 Days After Enrollment
Number of patients with at least one hospital readmission within 180 days after enrollment
180 days from baseline
Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 Health Scale - Patient-reported Outcome
6 months from baseline
Volunteer Peer Mentor + Behavioral Health Nurse
Care as Usual
Intervention group participants receive intervention services from a Volunteer Peer Mentor and a Behavioral Health Nurse
Registry-reported names are shown in full. Names without a link have not yet been matched to a Syfrah profile.
Scripps Mercy Chula Vista
Chula Vista, California, 91910, United States
Gallo LC, Fortmann AL, Clark TL, Roesch SC, Bravin JI, Spierling Bagsic SR, Sandoval H, Savin KL, Gilmer T, Talavera GA, Philis-Tsimikas A. Mi Puente (My Bridge) Care Transitions Program for Hispanic/Latino Adults with Multimorbidity: Results of a Randomized Controlled Trial. J Gen Intern Med. 2023 Jul;38(9):2098-2106. doi: 10.1007/s11606-022-08006-1. Epub 2023 Jan 25.
Gallo LC, Fortmann AL, Bravin JI, Clark TL, Savin KL, Ledesma DL, Euyoque J, Sandoval H, Roesch SC, Gilmer T, Talavera GA, Philis-Tsimikas A. My Bridge (Mi Puente), a care transitions intervention for Hispanics/Latinos with multimorbidity and behavioral health concerns: protocol for a randomized controlled trial. Trials. 2020 Feb 12;21(1):174. doi: 10.1186/s13063-019-3722-8.
The study may not have captured all readmissions since there are many regional hospitals. Other evolving approaches, such as the use of statewide health information exchanges, may improve ascertainment in future research. We did not delineate preventable from nonpreventable readmissions and did not have information on readmission acuity. Although some hospitalizations may have occurred due to COVID-19, it is likely that this affected both groups equally.
Athena Philis-Tsimikas, MD
Scripps Whittier Diabetes Institute
Linda Gallo, PhD
San Diego State University
536 participants (actual enrollment reported by the registry).
First Submitted
December 1, 2015
First Posted
March 30, 2016
Study Start
July 14, 2016
Actual (reported)Improving Medication Adherence Among Underserved Patients With Type 2 Diabetes
Patient Activation Measure (PAM) 13-Item - Patient-reported Outcome
6 months from baseline
Self-Management Resources for Chronic Disease, Chronic Illness Resources Survey (CIRS) - Short Version - Patient-reported Outcome
6 months from baseline
Number of Outpatient Visits Over the Past 6 Months - Patient-reported
6 months from baseline
Contact the study team to confirm eligibility.
Primary Completion
November 30, 2020
Actual (reported)Study Completion
November 30, 2020
Actual (reported)Last Updated
February 28, 2023
Results First Posted
February 28, 2023
Record last verified: 2023-02
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Source: ClinicalTrials.gov.
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