N/A N=1,679 Randomized Single-blind Other

Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions

Adverse Events · Readmissions · Patient Engagement

Bottom Line

View on ClinicalTrials.gov: NCT02130570 ↗

Enrolled (actual)

1,679

Serious AEs

0.0%

Results posted

Aug 2019

Primary outcome: Primary: Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date — 0.18; 0.23 proportion of participants — p=0.02

Study Design & Population

Study type: Interventional
Phase: N/A
Interventions: Multi-Model Intensive Discharge Intervention (Other)
Age: Adult, Older Adult · 18+ yrs
Sex: All
Sponsor: Brigham and Women's Hospital
Primary completion: Nov 2015

Outcome Measures

Outcome	Result	p-value
PRIMARY Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date	0.18; 0.23	0.02 sig
SECONDARY Proportion of Participants With New or Worsening Signs/Symptoms Within 30 Days of Discharge	0.90; 0.92	0.01 sig
SECONDARY Number of Patients With a Nonelective Readmission Within 30 Days of the Index Discharge Date	107; 78	0.77
SECONDARY Change in Functional Status on the Modified Medical Outcomes Survey Short Form-12 (SF-12v2) From One Month Prior to Admission to 30 Days After Discharge.	47.25; 46.14	0.91
SECONDARY Proportion of Participants With Positive Responses Regarding Patient Engagement and Opinions of the Discharge Process	.86; .85; .86; .88; .92; .90	0.57
SECONDARY Post-Discharge Health Care Utilization	—	—

Summary

The objective of this study is to design and implement a set of procedures (the intervention) to improve patients' experiences when they are discharged home from the hospital. Second, this study aims to look at how the intervention affects problems that are known to occur after discharge, including medication issues, worsening medical problems, or readmission to the hospital. The investigators will study how well patients recover the ability to do the things they could before they were admitted to the hospital and their opinions of the discharge process. Lastly, this study will look to understand the best way to implement the intervention into different hospitals and practices, and which types of patients benefit from it most.

Eligibility Criteria

Inclusion Criteria

Potential subjects will be adult patients admitted to medical and surgical services at BWH and MGH, likely to be discharged back to the community, and whose PCP belongs to one of the Partners Community Healthcare, Inc. (PCHI) primary care practices that has met "Primed" criteria for being a PCMH, admits at least 2 patients to BWH or MGH, and has agreed to participate. Primed criteria are a standard set of requirements that cover 6 essential building blocks of PCMH practices: electronic health record, patient portal, team-based care, practice redesign, care management, and identification of high-risk patients. We estimate that of the approximately 300 PCHI adult primary care practices, 150 of them will meet PCMH criteria during the study and that 20 of them will qualify and be willing to participate in the study. We estimate that 12,000 such patients will be admitted to BWH and MGH over the 18-month study period, of which we will enroll 1700 patients. These patients are broadly representative of hospitalized patients and include several vulnerable populations, including the elderly (33% 65 or older), patients with multiple chronic conditions (47% with Elixhauser comorbidity score 5 or more), and racial and ethnic minorities (14% African American, 13% Latino).

Exclusion Criteria

Likely discharge to a location other than home (or to a caregiver's home)
Police custody
No telephone or homeless
Previous enrolment in the study
Patient unable to communicate in either English or Spanish

View full record on ClinicalTrials.gov →

Data sourced from ClinicalTrials.gov (NCT02130570). 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.