Effectiveness of Transitional Care Services

NCT03353155 | Completed

• 1 other identifier: NUHSCareHub
• Study Type: interventional
• Target: 270
• Locations: 1 country
• Sites: 1

Brief Summary

The National University Hospital System has designed and is piloting an improved post-discharge care programme called CareHub for patients undergoing cardiac surgery. CareHub is a post-discharge care programme that is designed to streamline and better coordinate current programmes for patients at high risk of readmission. To assess the clinical and cost-effectiveness of CareHub, our team will randomly assign patients to a usual care setting or CareHub setting, and measure clinical outcomes, patient satisfaction, readmissions, and length of stay through 6 months post-discharge in both groups.Patients enrolled in both groups will receive post-discharge care for six months after discharge. CareHub patients will receive a single point of contact for access to usual care services. Recruitment for this pilot will be from 20 April 2016 - approximately late October 2016, and the CareHub team will provide 6 months of post-discharge support. The entire pilot will thus run from 20 April 2016 - April / May 2017, with data collection extending 6 months after the last patient is enrolled.

Conditions

Post-cardiac Surgery

Outcome Measures

Primary Outcomes (4)

• Post-discharge length of stay

  Patient's length of stay for any readmissions following index admission

  6 months

• Unplanned readmissions

  Whether patients were admitted for a cardiac complaint after index admission

  6 months

• Cardiac-related specialist outpatient clinic visits

  The number of post-index admission visits to an outpatient clinic for cardiac consults

  6 months

• Emergency department visits

  The number of emergency department visits post-index admission

  6 months

Secondary Outcomes (1)

• Net cost of service utilization

  6 months

Study Arms (2)

Usual Care

ACTIVE COMPARATOR

Telephone and/or home visits at 1 week, and thereafter, monthly for 6 months, to check on medication compliance and/or medical social problems and/or physical therapy needs and/or health-related financial challenges by the relevant service departments as recommended by the discharging physician.

Behavioral: Usual Care

CareHub

ACTIVE COMPARATOR

Telephone follow-up by a nurse care coordinator acting as single point of contact for medication compliance and/or medical social problems and/or physical therapy needs and/or health-related financial challenges based on automatic enrollment using ACE score cut-off at admission.

Behavioral: CareHub

Interventions

Usual Care BEHAVIORAL

Usual Care

CareHub BEHAVIORAL

CareHub

Eligibility Criteria

• Age: 18 Years - 99 Years
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• All patients admitted to the cardiac inpatient service post-cardiac surgery

You may not qualify if:

• Patients that do not consent or are unable to consent to be included into CareHub

Sponsors & Collaborators

• Johns Hopkins University: lead
• National University Health System, Singapore: collaborator

Study Sites (1)

National University Hospital

Singapore, Singapore

Location

Related Publications (7)

• Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009 Apr 2;360(14):1418-28. doi: 10.1056/NEJMsa0803563.

  PMID: 19339721 BACKGROUND

• Coleman EA. Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. J Am Geriatr Soc. 2003 Apr;51(4):549-55. doi: 10.1046/j.1532-5415.2003.51185.x.

  PMID: 12657078 BACKGROUND

• Greysen SR, Harrison JD, Kripalani S, Vasilevskis E, Robinson E, Metlay J, Schnipper JL, Meltzer D, Sehgal N, Ruhnke GW, Williams MV, Auerbach AD. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017 Jan;26(1):33-41. doi: 10.1136/bmjqs-2015-004570. Epub 2016 Jan 14.

  PMID: 26769841 BACKGROUND

• Wee SL, Loke CK, Liang C, Ganesan G, Wong LM, Cheah J. Effectiveness of a national transitional care program in reducing acute care use. J Am Geriatr Soc. 2014 Apr;62(4):747-53. doi: 10.1111/jgs.12750. Epub 2014 Mar 17.

  PMID: 24635373 BACKGROUND

• Coleman EA, Smith JD, Frank JC, Min SJ, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: the Care Transitions Intervention. J Am Geriatr Soc. 2004 Nov;52(11):1817-25. doi: 10.1111/j.1532-5415.2004.52504.x.

  PMID: 15507057 BACKGROUND

• Naylor M, Brooten D, Jones R, Lavizzo-Mourey R, Mezey M, Pauly M. Comprehensive discharge planning for the hospitalized elderly. A randomized clinical trial. Ann Intern Med. 1994 Jun 15;120(12):999-1006. doi: 10.7326/0003-4819-120-12-199406150-00005.

  PMID: 8185149 BACKGROUND

• Allen J, Hutchinson AM, Brown R, Livingston PM. Quality care outcomes following transitional care interventions for older people from hospital to home: a systematic review. BMC Health Serv Res. 2014 Aug 15;14:346. doi: 10.1186/1472-6963-14-346.

  PMID: 25128468 BACKGROUND

Study Officials

• John Wong, MD, PhD

  National University Hospital System

  PRINCIPAL INVESTIGATOR

• Phillip Phan, PhD

  Johns Hopkins University

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: HEALTH SERVICES RESEARCH
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: Patients are randomly assigned to one of two groups. Group 1 is usual care, in which patients are followed up after surgery by the ambulatory clinic assigned to their case. Patients in usual care have access to occupational and physical therapy, and medical social work, if they choose to use them. Group 2 is CareHub, in which patients are followed up by a dedicated care coordinator who proactively calls patients at home and schedules their clinic appointments, and consults with therapists and medical social workers.

Study Record Dates

• First Submitted: November 12, 2017
• First Posted: November 27, 2017
• Study Start: July 1, 2016
• Primary Completion: November 30, 2016
• Study Completion: October 1, 2017
• Last Updated: August 24, 2018

Record last verified: 2018-08

Data Sharing

• IPD Sharing: Will not share

Locations

SG (1)