Reducing Readmission Rates by Providing a Comprehensive Transition Plan From Hospital to Home for Cardiac Surgery Patients.

NCT04373850 | Completed

• 1 other identifier: IRB00097613
• Study Type: interventional
• Target: 450
• Locations: 0 countries
• Sites: N/A

Brief Summary

Patients who undergo cardiac surgery will be screened by a team member with the risk score once the patient has been admitted to the Cardiovascular Progressive Care Unit (CVPCU) after surgery. Participants will be randomized to the intervention or the control group. Both groups will receive standard discharge planning. In addition, the intervention group will have a nurse practitioner (NP) who will be responsible to verify that each essential step of the discharge process has been completed and will visit the patient in patient's home after discharge to complete a physical, review medications, titrate medications as needed, prescribe any necessary treatments, and perform education. The primary outcome variable will be a decrease in the 30 day readmission rate comparing high risk patients at pre and post intervention.

Conditions

Cardiac Surgery

Keywords

Reducing readmissions

Outcome Measures

Primary Outcomes (1)

• 30-Day readmission rate

  Rate of readmissions within 30 days after discharge

  Up to 30 days post discharge

Study Arms (2)

Home visit group

EXPERIMENTAL

Will receive a home visit after discharge in addition to the standard discharge planning.

Behavioral: Home Visit

Control group

NO INTERVENTION

Will receive only the standard discharge planning.

Interventions

Home Visit BEHAVIORAL

Physical exam, medication dose titration

Home visit group

Eligibility Criteria

• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Child (0-17), Adult (18-64), Older Adult (65+)

You may qualify if:

• All patients 18 years of age or greater who have had cardiac surgery procedures including coronary artery bypass surgery (CABG), valve replacement, aortic aneurysm repair, and combined CABG and valve procedures.

You may not qualify if:

• Patients who have undergone orthotopic heart transplantation, orthotopic lung transplantation, or orthotopic heart-lung transplantation
• Patients who have undergone ventricular assist device placement
• Patients who do not reside in Maryland
• Non English speaking patients
• Patients discharged to a facility.

Sponsors & Collaborators

• Johns Hopkins University: lead

MeSH Terms

Interventions

House Calls

Intervention Hierarchy (Ancestors)

Professional Practice; Organization and Administration; Health Services Administration

Study Officials

• Sharon Owens, PhD

  Johns Hopkins University

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: April 30, 2020
• First Posted: May 5, 2020
• Study Start: May 23, 2016
• Primary Completion: March 26, 2020
• Study Completion: March 26, 2020
• Last Updated: May 5, 2020

Record last verified: 2020-04