A Randomized Control Trial of the Coordinated-Transitional Care (C-TraC) Intervention for Dementia Patients
Overview
- Phase
- N/A
- Intervention
- Not specified
- Conditions
- Dementia
- Sponsor
- University of Wisconsin, Madison
- Enrollment
- 584
- Locations
- 1
- Primary Endpoint
- Change from baseline in rehospitalizations at 14, 30 and 90-days
- Status
- Completed
- Last Updated
- 5 years ago
Overview
Brief Summary
The goal of the project is to conduct a prospective, randomized-controlled clinical trial to determine the extent to which the Coordinated-Transitional Care (C-TraC) program impacts transitional care quality, patient cognition/function, caregiver stress and 30-day rehospitalizations in patients with documented diagnoses of dementia discharged from the hospital to the community.
Detailed Description
Patients with dementia often experience poor quality transitions from the hospital to the community. In response, the investigators developed and piloted the Coordinated-Transitional Care (C-TraC) program--a low-cost, telephone-based intervention designed to improve care coordination and outcomes in hospitalized patients with dementia or other high-risk conditions discharged to community settings. A single-blind, prospective, randomized-controlled trial will be used with participants being randomly assigned to receive usual (i.e. standard) care, or usual care plus the C-TraC intervention. Outcomes will be assessed via scheduled phone-calls at 14, 30, and 90 days post-hospitalization. A 45-day phone call will also be conducted to complete a brief satisfaction survey with the caregiver about their post-hospital experience.
Investigators
Eligibility Criteria
Inclusion Criteria
- •English-speaking
- •Have a working telephone
- •Hospitalized on medical inpatient wards at UWHC
- •A documented pre-hospitalization diagnosis of dementia.
- •Alzheimer's Disease Cooperative Study - Clinical Dementia Rating (ADCS-CDR) score of \> 0
- •Have a family member/informal caregiver who has regular contact with them in the community setting
- •Caregiver Inclusion Criteria:
- •English-speaking
- •Have a working telephone
- •Have contact with patient a minimum of once per week
Exclusion Criteria
- •Discharged to institutional settings
- •No identified caregiver
- •Discharged to hospice
- •Followed by complex case management or any form of intensive case management (e.g. transplant, congestive heart failure, dialysis)
- •Score moderate-high on modified ASSIST tool for alcohol
Outcomes
Primary Outcomes
Change from baseline in rehospitalizations at 14, 30 and 90-days
Time Frame: 14, 30 and 90-days
The presence of any rehospitalization will be assessed through a combination of 14, 30 and 90 day structured phone calls directly to patients/caregivers, a detailed review of medical records associated with any of these caregiver/patient reported rehospitalizations, and a detailed review of the patient's UWHC medical records after all phone calls are completed.
Secondary Outcomes
- Patient functional maintenance/recovery(14, 30 and 90-days)
- Increase in patient delirium prevention/resolution(14, 30 and 90-days)
- Patient falls prevention(14, 30 and 90-days)
- Decrease caregiver stress(14, 30 and 90-days)