Improving Hospital-to-Home Care Transitions for High-risk Younger Adult Patients
Completed · Not applicable
Conditions studied: Patient Discharge
In brief
Improving hospital-to-home care transitions can produce improvements in patient safety and health care outcomes, while decreasing medical costs. Most transitions research has examined strategies for older patients. This project, however, focuses on younger, high-risk patients within a safety net system. The proposed intervention is based on research that patient activation, as measured by the Patient Activation Measure (PAM), is correlated with risk for hospital readmission. The intervention seeks to increase PAM scores by employing a Transition Coach to coach patients, prior to and for 30-days after discharge, to (1) improve self-management skills through goal setting and goal attainment; (2) to enhance patient capacity to engage in trusting relationships with the Primary Care Provider (PCP), other medical specialists, family members of friends, and the Transition Coach; and (3) to improve ability to navigate the medical system. The investigators will conduct a randomized trial to determine; (a) if PAM scores can be increased in the 30-day after hospital discharge; (b) if increased PAM scores, in this setting, are correlated with changes in healthcare utilization patterns; and (c) if the intervention presents a viable strategy to change healthcare utilization patterns and reduce rehospitalizations.
Key facts
- Study ID
- NCT02532296
- Run by
- Cambridge Health Alliance
- People needed
- 201
- Starts
- 2015-06-01
- Expected to finish
- 2016-07-01
- Last updated by the study team
- 2016-08-05
Who can join
Age: 18 and older, up to 60. Sex: any. Healthy volunteers: accepted.
You may qualify if…
- Age 60 or less
- PCP within CHA network
- Have had at least one previous hospitalization or two or more Emergency Department visit within CHA in the past year
- Hospitalized at Cambridge Hospital on Medicine or Surgery Service
- Discharged from Medicine or Surgery service to home
You may not qualify if…
- Age > 60;
- Non-CHA PCP
- Discharged to rehabilitation or transferred to an outside hospital or to Psychiatry service
Where it is running
- Cambridge Hospital — Cambridge, Massachusetts, United States
Full record on ClinicalTrials.gov
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