Understanding Perspectives of Frequently-Admitted Hospital Patients

NCT03097640 | Completed

• 1 other identifier: STU00203847
• Study Type: interventional
• Target: 151
• Locations: 1 country
• Sites: 1

Brief Summary

This study evaluates the clinical outcomes of a novel program designed to target patients who are high-utilizers of hospital services. Patients who are frequently admitted to medical services - "high-utilizers" - present a unique set of challenges to providers and the health care system that require a different way of approaching chronic illness. The Complex High Admission Management Program (CHAMP) is an innovative model of care consisting of a small team of providers who establish continuity relationships with high-utilizer patients. CHAMP strives to provide effective, high value care via a longitudinal relationship-based care model through provider continuity, intensive case management, and personalized care plans. To better understand the potential outcomes of CHAMP, this study is a longitudinal, prospective, randomized, controlled trial of medical high-utilizers enrolled in CHAMP compared to a group of high-utilizer patients receiving usual care.

Conditions

Continuity of Patient Care; High Utilizers of Hospital Care; Patient-Centered Care

Outcome Measures

Primary Outcomes (1)

• Readmission Rate

  180-day Inpatient Readmission Rate (as defined by Medicare) to Northwestern Memorial Hospital

  180-days from indexed hospital discharge

Secondary Outcomes (22)

• Readmission Rate

  30 days from indexed hospital discharge

• Readmission Rate

  90 days from indexed hospital discharge

• Inpatient Admissions

  30 days from indexed hospital discharge

• Inpatient Admissions

  90 days from indexed hospital discharge

• Inpatient Admissions

  180 days from indexed hospital discharge

Study Arms (2)

CHAMP

EXPERIMENTAL

Participants enrolled in CHAMP are followed by a team of a social worker and physician across the care continuum. CHAMP team members visit patients in the ED and on inpatient floors. Along with the patient's input, the team develops an Individualized Care Plan outlining the patient's medical and social history and providing recommendations to other providers on specific aspects of their care. Care plans are reviewed with patients on an individual basis and reviewed periodically by the CHAMP providers. CHAMP-enrolled participants are scheduled for physician and social worker follow-up appointments at the CHAMP clinic; this time is used to provide intensive case management, medical care, and psychosocial support.

Other: CHAMP

Standard Care

NO INTERVENTION

Individuals in the standard care arm will receive care as they do normally when hospitalized, including medical and inpatient social work services, as well as outpatient care from their providers.

Interventions

CHAMP OTHER

CHAMP team members visit patients in the ED and on inpatient floors. Along with the patient's input, the team develops an Individualized Care Plan outlining the patient's medical and social history and providing recommendations to other providers on specific aspects of their care. Care plans are reviewed with patients on an individual basis and reviewed periodically by the CHAMP providers. CHAMP-enrolled participants are scheduled for physician and social worker follow-up appointments at the CHAMP clinic; this time is used to provide intensive case management, medical care, and psychosocial support.

CHAMP

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• Adults (18 yrs of age or older) who are admitted to Northwestern Memorial Hospital (NMH) and identified by EDW search as having two unplanned 30-day inpatient readmissions to NMH within the prior 12 months with one of two additional criteria:at least 1 readmission in the last 6 months, or a referral from one of that patient's medical providers.
• Admission to NMH during the study period (October 1, 2016 to September 30, 2018) and meeting criteria described above for CHAMP
• Ability to consent for this study (including ability to read materials printed in English, understanding and communicating in English, and able to understand the risks and benefits of participating in the study).

You may not qualify if:

• Patients who are admitted to the Intensive Care Unit, patients admitted to Oncology services (as we have found that this latter group has a multidisciplinary care team already in place), or patients actively followed by the Heart Failure Bridge and Transition (BAT) Team, a different quality improvement intervention designed to reduce readmissions among patients admitted for acute decompensated heart failure.
• Participants will be excluded if they are disoriented to person, place, or time, or are unable to consent for any other reason.
• Minors, pregnant women, and prisoners will also be excluded.

Sponsors & Collaborators

• Northwestern University: lead

Study Sites (1)

Northwestern Memorial Hospital

Chicago, Illinois, 60611, United States

Location

Related Publications (1)

• Henschen BL, Theodorou ME, Chapman M, Barra M, Toms A, Cameron KA, Zhou S, Yeh C, Lee J, O'Leary KJ. An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial. J Gen Intern Med. 2022 Jun;37(8):1877-1884. doi: 10.1007/s11606-021-07048-1. Epub 2021 Sep 1.

  PMID: 34472021 DERIVED

Study Officials

• Bruce L Henschen, MD/MPH

  Northwestern University Feinberg School of Medicine

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: OUTCOMES ASSESSOR
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Assistant Professor

Study Record Dates

• First Submitted: March 27, 2017
• First Posted: March 31, 2017
• Study Start: November 1, 2016
• Primary Completion: July 1, 2020
• Study Completion: October 1, 2021
• Last Updated: October 4, 2021

Record last verified: 2021-10

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)