Intervening With and Improving Care for Patients at Risk for Frequent Hospital Admissions

Completed · Phase 1

Conditions studied: Hospitalization, Patient Readmission

In brief

Patients with frequent hospital admissions account for a disproportionate share of visits and costs. An intervention that can bridge the gap between hospital and community based care for a population of patients with frequent hospital admissions may offer both improved care and cost savings if hospital admissions can be appropriately reduced. We are now using data from our previous research to inform the development and implementation of an intervention at Bellevue Hospital, which will bridge the gap between hospital and community based care for a population of patients with frequent hospital admissions. We hypothesize that such an intervention can offer both improved care and cost savings if hospital admissions can be appropriately reduced. In this protocol we outline a strategy to pilot a small-scale intervention on a small subset of patients admitted to an urban public tertiary care safety net hospital who are defined by our study criteria as at high risk for future readmission. By piloting components of the intervention, we aim to assure the intervention functions as planned, and can deliver the needed services to high risk patients in a seamless and patient-centered manner. The purpose of this "feasibility study" is to ensure that when our intervention is implemented on a larger scale, it appropriately serves enrolled patients needs, and that we are able to effectively follow patients during the intervention period.

Key facts

Study ID

NCT01292096

Run by

NYU Langone Health

People needed

19

Starts

2007-08-01

Expected to finish

2009-03-01

Last updated by the study team

2016-03-02

Who can join

Age: 18 and older, up to 64. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• Patients identified at the time of a current hospital admission by a predictive algorithm (algorithmic risk score of 50 or greater) as being at high risk for hospital readmission in the following 12 months
• English or Spanish speaking
• Fee-for-service Medicaid or uninsured patients
• Ages 18-64

You may not qualify if…

• Neither English or Spanish-speaking,
• Institutionalized when not admitted to the hospital
• Unable to communicate
• HIV positive (because HIV positive patients have resources available to them from different and unrelated funding streams, and receive primary care at an off-site location)

Where it is running

• Bellevue Hospital Center Department of Emergency Medicine, A345 — New York, New York, United States

Full record on ClinicalTrials.gov

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