Care Transitions for Complex Patient - Cycle 1 and Cycle 2
Completed · Not applicable
Conditions studied: Asthma, Coronary Artery Disease, Diabetes, Hypertension, Congestive Heart Failure
In brief
The purpose of this study is to improve patient care and safety while decreasing ED visit rates by sending specific information about care transitions related to hospital admission and discharge and emergency department and specialty care visits to primary care practices, care managers and patients with the use of health information technology (HIT) shared across a community-based network of providers. Cycle 1 focuses on the impact of notices about ED encounters and hospitalizations derived from billing data that are sent to care managers for all 47,000 patients in the Northern Piedmont Community Care Network (NPCCN). Cycle 2 explores the impact of letters sent to patients, and care event reports sent to a patient's medical home in addition to notices sent to care managers about ED encounters, hospitalization and specialty care based on ADT (Admission Discharge Transfer) and billing data on 4,600 patients with complex health needs.
Key facts
- Study ID
- NCT01039324
- Run by
- Duke University
- People needed
- 8422
- Starts
- 2009-12-01
- Expected to finish
- 2012-09-01
- Last updated by the study team
- 2014-05-15
Who can join
Age: any. Sex: any. Healthy volunteers: not accepted.
You may qualify if…
- North Carolina Medicaid beneficiary enrolled in the Northern Piedmont Community Care Network (NPCCN)
- Has complex healthcare needs as defined by having two or more IOM (Institute of Medicine) priority conditions (hypertension, coronary artery disease, congestive heart failure, stroke, asthma, diabetes) OR one of the following: moderate to severe mental health diagnosis (schizophrenic disorder, episodic mood disorder, delusional disorder, non-organic psychosis, anxiety, dissociative-somatoform disorder, personality disorder), end-stage renal disease, sickle cell disease
- Continuous enrollment in NPCCN for 10 of the previous 12 months
Where it is running
- Duke University Medical Center (Division of Clinical Informatics) — Durham, North Carolina, United States
Full record on ClinicalTrials.gov
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