Discharge Information and Support for Patients Receiving Outpatient Care in the Emergency Department

Completed · Not applicable

Conditions studied: Multimorbidity

In brief

The Veterans' Health Administration (VHA) is committed to improving primary care through the implementation of Patient Aligned Care Teams (PACTs). Improving access to services and care coordination are among the primary goals of PACTs; however, there remain many unanswered questions about how best to use the limited time of PACT team members, such as nurse care managers, to accomplish this. This study will evaluate the effectiveness of a nurse-led telephone support program for Veterans who have been treated recently in the emergency department (ED) and are at high risk for repeat visits. The program's goals are to reduce the need for future ED use and improve satisfaction among Veterans by providing information and support related to the ED visit, enhancing chronic disease management and educating Veterans and family members about PACT and other VA and community services. If proven effective, this program could improve health and healthcare for a large, vulnerable group of Veterans and be cost saving for VHA.

Key facts

Study ID

NCT01717976

Run by

VA Office of Research and Development

People needed

513

Starts

2013-12-01

Expected to finish

2016-11-01

Last updated by the study team

2017-07-25

Who can join

Age: any. Sex: any. Healthy volunteers: not accepted.

You may qualify if…

• To be included in the study, patients must meet all of the following:
• Treated and released from the Durham VA ED;
• Receive primary care from a Durham VAMC affiliated primary care clinic (at least one visit in a primary care clinic affiliated with the Durham VAMC within the previous 12 months);
• At least one VAMC ED visit or hospital admission within the 6 months preceding the index visit;
• Diagnosed with 2 or more chronic health conditions; and
• Valid telephone number in the medical record; in the investigators' pilot studies, 98.7% of Veterans had a valid phone number in the medical record.

You may not qualify if…

• Patients will be excluded if they meet any of the following:
• Reside in a nursing home (or other institutional setting);
• Unable to communicate on the telephone, and no proxy available;
• Lacks decision-making capacity, and no proxy available; or
• Returned to ED within 24 hours of discharge from initial visit.
• Have a current Category 1 high-risk suicide flag on their CPRS medical record; or Visit the PEC (Psychiatric Emergency Clinic) within 24 hours of discharge from initial ED visit.
• Enrolled in a study that prohibits cross-enrollment in other studies.

Where it is running

• Durham VA Medical Center, Durham, NC — Durham, North Carolina, United States

Full record on ClinicalTrials.gov

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