Ignite Creation Date:
2024-05-06 @ 2:27 AM
Last Modification Date:
2024-10-26 @ 11:18 AM
Study NCT ID:
NCT02045147
Status:
COMPLETED
Last Update Posted:
2017-05-12
First Post:
2014-01-22
Brief Title:
Home Based Care Transitions Tailored by Cognition and Patient Activation
Sponsor:
University of Nebraska
Organization:
University of Nebraska
Study Overview
Official Title:
Home Based Care Transitions Tailored by Cognition and Patient Activation A Prudent Use of Transitional Care Resources
Status:
COMPLETED
Status Verified Date:
2024-09
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Not Stopped
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief 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
Detailed Description:
One in five Medicare patients discharged from the hospital experience readmission within 30 days Too often hospital readmissions result from inadequate transition from hospital to home at discharge Care transitions are complicated because of high patient acuity multiple comorbidities decreased length of stay and multiple clinician involvement increasing the number of handoffs With decreased length of stay many patients do not comprehend or feel confident with instructions for discharge thus management of their chronic illnesses are difficult Most formal care transition programs are standardized and every patient receives similar strategies or interventions However it has been well documented that patients with cognitive problems and decreased activation are at high risk for re-hospitalization related to impaired self-management We believe that assessment of cognition and patient activation during the patients hospitalization will provide valuable information for discharge interventions Data related to cognition and activation can be used to tailor discharge planning and help determine what type and how many resources are needed for individual patients after hospital discharge The purpose of this feasibility study is to examine the impact of delivering a home based care transitions interventions HBCTIs with four different groups tailored on cognition and level of patient activation compared to usual care UC 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 discharged to home from the hospital
We will test our intervention with the following aims Aim 1To evaluate the impact of HBCTIs on health care utilization We will measure HCU number of emergency departmentED visits and number of readmissions at 6 months after discharge Our working hypothesis is that patients in the HBCTI groups compared to the UC groups will have lower HCU over time 6 months Aim 2 To evaluate the impact of HBCTIs on the following health outcomes patient-reported health status PROMIS-29 assessment of care for chronic conditions PACIC and quality of life EuroQol Our working hypothesis is that patients in the HBCTI groups compared to the UC group will have improved patient-reported health status assessment of care for chronic conditions and quality of life EuroQol at 6 months after discharge
The findings from this study have the potential to change this paradigm in three ways 1 we will gain a better understanding of the role of cognition and patient activation in promoting self-management to enhance outcomes 2 our innovative approach which considers the unique needs of patients based on their level of cognition and patient activation will advance new concepts in care transition programs 3 we will have a better understanding of varying intensities of visits level of providers and type and amount of strategies administered This practical model for care transitions could serve as a model within the larger health care delivery system that could result in significant cost savings
We will test our intervention with the following aims Aim 1To evaluate the impact of HBCTIs on health care utilization We will measure HCU number of emergency departmentED visits and number of readmissions at 6 months after discharge Our working hypothesis is that patients in the HBCTI groups compared to the UC groups will have lower HCU over time 6 months Aim 2 To evaluate the impact of HBCTIs on the following health outcomes patient-reported health status PROMIS-29 assessment of care for chronic conditions PACIC and quality of life EuroQol Our working hypothesis is that patients in the HBCTI groups compared to the UC group will have improved patient-reported health status assessment of care for chronic conditions and quality of life EuroQol at 6 months after discharge
The findings from this study have the potential to change this paradigm in three ways 1 we will gain a better understanding of the role of cognition and patient activation in promoting self-management to enhance outcomes 2 our innovative approach which considers the unique needs of patients based on their level of cognition and patient activation will advance new concepts in care transition programs 3 we will have a better understanding of varying intensities of visits level of providers and type and amount of strategies administered This practical model for care transitions could serve as a model within the larger health care delivery system that could result in significant cost savings
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None