Study of the Impact of a Hospital Discharge Care Coordination Program in an Elderly Population

Completed · Not applicable

Conditions studied: Hospital Readmission

In brief

The purpose of this research study is to evaluate the effect of a health information exchange (HIE)-supported care coordination package on 30-day readmission rates in a frail elderly population.

Key facts

Study ID

NCT01440907

Run by

Weill Medical College of Cornell University

People needed

201

Starts

2011-05-01

Expected to finish

2013-07-01

Last updated by the study team

2017-01-24

Who can join

Age: 65 and older. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• Weill Cornell Investigators will be receiving a HIPAA-compliant de-identified dataset from the Brooklyn Health Information Exchange (BHIX) that includes:
• Demographic data information
• Diagnoses (admission, discharge, readmission)
• Whether the patient was readmitted readmission, # of inpatients days if the patients was readmitted
• Care coordination program statistics (e.g. usage of the personal health record, and frequency of contact with nursing support staff).
• The data set will include data of the following individuals:
• Intervention Dataset (Group 1): Those age 65 or older who are discharged from Maimonides to home during the study period and enrolled in the Care Coordination Program.
• Control Dataset (Group 2): Those age 65 or older who are discharged from Maimonides to home during the study period.

You may not qualify if…

• The exclusion criteria for this study for both the intervention \& control dataset is anybody who does not fall into the above inclusion category and anybody who was:
• Transferred on the day of discharge to another acute care hospital, admitted to a hospital specialty unit, admitted to an inpatient rehabilitation facility, or admitted to a long-term care hospital;
• Approached and declined to participate in the Care Coordination Program.

Where it is running

• Maimonides Medical Center — Brooklyn, New York, United States
• Brooklyn Health Information Exchange (BHIX) — Brooklyn, New York, United States

Full record on ClinicalTrials.gov

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