A Virtual Ward to Reduce Readmissions After Hospital Discharge
Overview
- Phase
- Not Applicable
- Intervention
- Not specified
- Conditions
- Acute Disease
- Sponsor
- Unity Health Toronto
- Enrollment
- 1928
- Locations
- 5
- Primary Endpoint
- Composite of readmission to hospital or death.
- Last Updated
- 12 years ago
Overview
Brief Summary
The purpose of this study is to see whether a Virtual Ward reduces readmissions after hospital discharge.
Detailed Description
We will conduct a pragmatic, randomized controlled trial to evaluate a new model of care for high-risk medical patients after discharge from hospital. This new model of care has two key elements. First, we will use the LACE index (see citation below for details) to identify patients who are at high risk of readmission or death after hospital discharge. These patients will be randomized to either the Virtual Ward or usual care on the day of discharge. Although patients being cared for in the Virtual Ward will reside at home, they will benefit from a hospital-like interdisciplinary team, a shared set of notes, a single point of contact, round-the-clock physician availability and increased co-ordination of specialist, primary and home-based community care for several weeks after hospital discharge.
Investigators
Irfan Dhalla
Staff Physician & Scientist
Unity Health Toronto
Eligibility Criteria
Inclusion Criteria
- •Discharge from medical service
- •LACE score greater than or equal to 10
- •Age greater than or equal or 18
- •Resident in Toronto Central Local Health Integration Network catchment area
- •Patient or designate able to speak English well enough for follow up telephone calls
Exclusion Criteria
- •Previously enrolled in study
- •Discharged to a rehabilitation or complex continuing care facility
Outcomes
Primary Outcomes
Composite of readmission to hospital or death.
Time Frame: 30 days after hospital discharge
A binary outcome variable for each patient, representing either readmission to hospital or death within 30 days of hospital discharge. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences.
Secondary Outcomes
- Long-term care admission(One year after discharge)
- Composite of readmission to hospital or death.(One year after discharge)
- Emergency department visits(One year after discharge)
- Composite of readmission or death(One year after discharge)
- Death(One year after discharge)
- Readmission(One year after discharge)