A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
- Conditions
- Chronic Diseases
- Interventions
- Other: a transitional care modelOther: Control
- Registration Number
- NCT02351648
- Lead Sponsor
- Singapore General Hospital
- Brief Summary
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH
- Detailed Description
Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending
Primary Aim:
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH
Secondary Aim:
To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)
Recruitment & Eligibility
- Status
- COMPLETED
- Sex
- All
- Target Recruitment
- 840
Not provided
Not provided
Study & Design
- Study Type
- INTERVENTIONAL
- Study Design
- PARALLEL
- Arm && Interventions
Group Intervention Description Intervention' a transitional care model Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients Control' Control Patients receive usual standard of care from the internal medicine team
- Primary Outcome Measures
Name Time Method Readmission rate 30 days after index discharge A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients
- Secondary Outcome Measures
Name Time Method Readmission rate up to 180 days after index discharge Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge
Specialist Outpatient Clinic visits Up to 180 days after index discharge Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge
Quality of transitional care using a validated care transition measure (CTM-15) tool 90 days after index discharge Care transition measure survey of subjects
Emergency department attendance rate Up to 180 days after index discharge Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge
Time to first readmission Up to 90 days after index discharge Censored time to readmission for both intervention and control group
Trial Locations
- Locations (1)
Singapore General Hospital
🇸🇬Singapore, Singapore