Implementation and Evaluation of A Health Innovation to Support Medicaid-Insured Individuals Following Hospitalization

NCT05714605 | Enrolling By Invitation

• 1 other identifier: 10080229
• Study Type: interventional
• Target: 267
• Locations: 1 country
• Sites: 1

Brief Summary

The goal of this stepped wedge pragmatic trial is to compare referral patterns and post discharge outcomes in Medicaid insured individuals discharge following a hospitalization\]. The aims are to 1) evaluate the implementation of the THRIVE clinical pathway, including feasibility, appropriateness, and acceptability and 2) examine referral patterns, 30- day readmission and Emergency Department (ED) utilization patterns for participants who receive THRIVE support services. During hospitalization participants will receive a referral to home care services and will be seen by a home care nurse within 48 hours following discharge. A discharging physician or Advanced Practice Provider will maintain clinical oversight for 30 days or until the patient sees primary care provider or specialist. A Care Coordination Team conducts weekly case conferences to ensure social and health needs are being addressed for 30 days post-discharge. Researchers will compare Medicaid insured patients discharged during the study, to those receiving usual care to determine if there are differences in post-acute utilization outcomes.

Conditions

Care Transitions

Outcome Measures

Primary Outcomes (4)

• Rates of Referrals to Homecare

  We will evaluate changes in home care referrals between case managers exposed to the intervention compared to those who were not.

  Through study completion, an average of 18 months

• Rates of Readmissions

  We will evaluate the rate of readmissions over the course of the study for THRIVE participants compared to those receiving usual care.

  30 days following hospital discharge

• Rates of Emergency Department Visit

  We will evaluate the rate of ED visits over the course of the study for THRIVE participants compared to those receiving usual care.

  30 days following hospital discharge

• Primary Care or Specialist Visit

  We will compare the rates of primary care provider and specialist visits within 30 days following discharge compared to those receiving usual care.

  30 Days following hospital discharge

Secondary Outcomes (1)

• Feasibility, Acceptability, Appropriateness, Workload

  Through study completion, an average of 18 months

Study Arms (2)

THRIVE Intervention

EXPERIMENTAL

1 month intensive post discharge case management and care coordination.

Behavioral: THRIVE Intervention

Usual Care

NO INTERVENTION

Discharge to home without intensive post acute case management or care coordination.

Interventions

THRIVE Intervention BEHAVIORAL

The THRIVE Clinical Pathway is a standardized transitional care clinical pathway that supports Medicaid insured or Medicaid eligible individuals following hospitalization.

THRIVE Intervention

Eligibility Criteria

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

You may qualify if:

• Medicaid insured
• Residing in the state of Pennsylvania
• Experienced a hospitalization at study hospital
• Agrees to home care at partner home care setting.

You may not qualify if:

• Individuals under age 18

Sponsors & Collaborators

• University of Pennsylvania: lead
• Rita & Alex Hillman Foundation: collaborator

Study Sites (1)

Pennsylvania Hospital

Philadelphia, Pennsylvania, 19107, United States

Location

Related Publications (1)

• Brooks Carthon JM, Brom H, Grantham-Murrillo M, Sliwinski K, Mason A, Roeser M, Miles D, Garcia D, Bennett J, Harhay MO, Flores E, Amenyedor K, Clark R. Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial. JMIR Res Protoc. 2024 Mar 26;13:e54211. doi: 10.2196/54211.

  PMID: 38530349 DERIVED

Study Officials

• Margo B Brooks Carthon, PhD RN

  University of Pennsylvania

  PRINCIPAL INVESTIGATOR

Study Design

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

Study Record Dates

• First Submitted: January 19, 2023
• First Posted: February 6, 2023
• Study Start: March 27, 2023
• Primary Completion (Estimated): May 30, 2026
• Study Completion (Estimated): June 30, 2026
• Last Updated: July 3, 2025

Record last verified: 2025-07

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)