N/A N=263 Randomized Treatment

Home Based Care Transitions Tailored by Cognition and Patient Activation

Chronic Disease

Bottom Line

View on ClinicalTrials.gov: NCT02045147 ↗

Enrolled (actual)

263

Serious AEs

0.0%

Results posted

Oct 2024

Primary outcome: Primary: Health Care Utilization — 7; 8; 4; 3 events

Study Design & Population

Study type: Interventional
Phase: N/A
Interventions: Grp 1a Low Cognition, Low Activation Intervention (Behavioral); Grp 2a Low Cognition, High Activation Intervention (Behavioral); Grp 3a Normal Cognition, Low Activation Intervention (Behavioral); Grp 4a Normal Cognition, High Activation Intervention (Behavioral)
Age: Adult, Older Adult · 19+ yrs
Sex: All
Sponsor: University of Nebraska
Primary completion: Dec 2014

Outcome Measures

Outcome	Result	p-value
PRIMARY Health Care Utilization	7; 8; 4; 3; 5; 13	—
SECONDARY Patient-Reported Outcomes Measurement Information System - Pain Interference	58.8; 57.0; 61.4; 54.2; 56.0; 55.4	0.463
SECONDARY Patient-Reported Outcomes Measurement Information System-Physical Functioning	39.1; 42.1; 36.3; 43.6; 41.1; 43.8	0.532
SECONDARY Patient-Reported Outcomes Measurement Information System-Satisfaction With Social Roles	49.3; 49.2; 43.8; 50.4; 44.1; 50.4	0.153
SECONDARY Patient-Reported Outcomes Measurement Information System- Anxiety	54.0; 51.0; 53.5; 46.6; 51.3; 46.8	0.521
SECONDARY Patient-Reported Outcomes Measurement Information System-Fatigue	54.8; 54.3; 56.7; 50.5; 55.9; 49.3	0.776
SECONDARY Patient-Reported Outcomes Measurement Information System- Depression	55.2; 50.5; 54.4; 49.4; 52.6; 47.4	0.564
SECONDARY Patient-Reported Outcomes Measurement Information System-Sleep Deprivation	50.1; 51.5; 53.5; 48.4; 50.5; 46.9	0.917
SECONDARY Patient Assessment of Chronic Illness Care	2.9; 2.9; 2.5; 3.0; 2.8; 3.2	0.872
SECONDARY Health Related Quality of Life EuroQol-5D (EQ-5D)	0.68; 0.76; 0.65; 0.80; 0.72; 0.77	0.627
SECONDARY EQ-5D Visual Analog Scale (VAS)	68.2; 67.2; 62.4; 73.5; 61.3; 79.0	.436

Summary

There is overwhelming evidence that patients with multiple chronic illnesses need better self-management skills. Discharge from the hospital may not be the most opportune time to be teaching patients these self-management skills. There are several different care transition models being used across the country; however we know that not every patient needs the same type or amount of an intervention. The purpose of this pilot study is to study the impact delivering a home based care transitions intervention (HBCTI) with four different groups tailored on cognition and level of patient activation compared to usual care (UC) resulting in 8 study arms on the outcomes of health care utilization (HCU) and health outcomes: patient-reported health status, assessment of care for chronic conditions, and health related quality of life in adult patients with multiple chronic diseases dismissed to home from an acute care facility. Our working hypothesis is that patients in the HBCTI groups compared to the UC groups will have lower HCU and improved outcomes (patient-reported health status, assessment of care for chronic conditions, and health related quality of life).

Eligibility Criteria

Inclusion Criteria

Adult Patients (age 19 and older) being discharged from the hospital with three or more chronic diseases;
Have a score greater than 17 on the Montreal Cognitive Assessment (dementia);
Reside within a 35 mile radius of Lincoln, Ne.; and
Able to hear, speak and read English.

Exclusion Criteria

Patients will be excluded if they:

have a terminal illness;
have a score of less than 17 on the Montreal Cognitive Assessment (dementia);
are under the care of The Physicians Network (TPN) at St. Elizabeth Regional Medical Center (SERMC).

View full record on ClinicalTrials.gov →

Data sourced from ClinicalTrials.gov (NCT02045147). Outcome figures and adverse-event rates are extracted automatically from the registry's posted results and are provided for clinician reference, not as a substitute for the primary publication.