N/A
Completed N=536
Mi Puente: My Bridge to Better Cardiometabolic Health and Well-Being
Type 2 Diabetes Mellitus · Cardiometabolic Conditions · Behavioral Health Concerns
Source: ClinicalTrials.gov NCT02723019 ↗
Enrolled (actual)
536
Serious AEs
0.0%
Results posted
Feb 2023
Primary outcomePrimary: Number of Patients With at Least 1 Hospital Readmission Within 30 Days After Enrollment — 43; 25 participants — p=0.01
Summary
Mi Puente (or "My Bridge") is a culturally-tailored, interdisciplinary approach designed to support at-risk Hispanic patients and their caregivers pre- and post-hospital discharge as they navigate the multi-level barriers that contribute to inequities in health care access and use, and in turn, perpetuate disparities in cardiometabolic and behavioral health. Mi Puente utilizes a sustainable nurse + volunteer peer team-based model, bridging partnership between inpatient and outpatient care settings to meet the integrated (i.e., physical and behavioral) health needs of Hispanics who are hospitalized with multiple chronic cardiometabolic conditions and one or more behavioral health concern(s). Participants will be tested at Scripps Mercy Hospital - a large, non-profit, safety net hospital located in the US/Mexico border region of South San Diego County, California. The proposed randomized controlled trial will test Mi Puente versus Usual Care (evidence-based, best practice discharge procedures) in improving hospital utilization, patient-reported, and cost effectiveness outcomes. Electronic medical records (EMR) will be used to identify eligible patients and examine primary outcomes.
Outcome Measures
| Outcome | Result | p-value |
|---|---|---|
| PRIMARY Number of Patients With at Least 1 Hospital Readmission Within 30 Days After Enrollment |
43; 25 | 0.01 sig |
| PRIMARY Number of Patients With at Least 1 Hospital Readmission Within 180 Days After Enrollment |
120; 98 | 0.19 |
| SECONDARY Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 Health Scale - Patient-reported Outcome |
29.74; 29.57 | 0.73 |
| SECONDARY Patient Activation Measure (PAM) 13-Item - Patient-reported Outcome |
66.15; 66.81 | 0.28 |
| SECONDARY Self-Management Resources for Chronic Disease, Chronic Illness Resources Survey (CIRS) - Short Version - Patient-reported Outcome |
3.14; 3.14 | 0.71 |
| SECONDARY Number of Outpatient Visits Over the Past 6 Months - Patient-reported |
5.39; 4.39 | 0.42 |
Eligibility Criteria
Inclusion Criteria
- Must be Hispanic
- Must be ≥18 years
- Must have ≥2 cardiometabolic conditions (e.g., obesity, diabetes, hypertension, dyslipidemia ischemic heart diseases, congestive heart failure, other chronic coronary conditions)
- Must have ≥1 behavioral health concern(s) (i.e., related to mental health, life stressors, medication adherence, healthcare use)
- Must have telephone access
Exclusion Criteria
- Pregnancy
- Serious life-threatening condition with life expectancy < 6 months
- Psychiatric morbidity or neurological/cognitive impairment of sufficient severity to preclude participation in the intervention
- Discharging to location other than home (e.g., nursing care)
- Does not speak Spanish or English
Data sourced from ClinicalTrials.gov (NCT02723019). 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. Informational only — not medical advice.