Implementation of a Primary Hospital Provider (PHP) Team

Not Applicable

Recruiting

• Conditions: High-need, High-complexity
• Interventions: Other: Primary Hospital Provider Team

• Registration Number: NCT06581224
• Lead Sponsor: University of Wisconsin, Madison

Brief Summary

The goal of this pragmatic clinical trial is to learn if it is possible to implement a Primary Hospital Provider (PHP) team that aims to improve continuity of care for patients who are frequently hospitalized. The main question it aims to answer is: Are patients assigned to the PHP team more likely to be assigned to this team during a follow up hospitalization? Researchers will compare this to similar patients assigned to receive usual care. Some participants from both the PHP team and usual care groups will be asked to participate in interviews to help researchers understand the needs of patients who are frequently admitted and the care they receive.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2024-08-29
• Study First Submitted QC: 2024-08-29
• Study First Posted: 2024-09-03
• Study Start: 2025-01-09
• Status Verified: 2025-04
• Last Update Submitted: 2025-04-21
• Last Update Posted: 2025-04-23
• Primary Completion: 2025-10
• Study Completion: 2025-11

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 700

Inclusion Criteria

• Age greater than 18 at the time of index admission
• Two or more hospitalizations to a general medicine service at UW Health (University Hospital or East Madison Hospital) within the past 12 months AND an EPIC Readmission Risk Score of greater than a predetermined value

Exclusion Criteria

• Outpatient primary care provider is part of the UW Health Family Medicine service that currently admits their own patients to a separate service at University Hospital
• Patients with an oncologic diagnosis for which they are actively receiving chemotherapy or immunotherapy
• Prisoners
• Pregnant women

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
PHP Team	Primary Hospital Provider Team	PHP Team

Primary Outcome Measures

Name	Time	Method
Number of patients readmitted to the PHP team	11.5 months	The number of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
Number of patients readmitted to usual care team	11.5 months	The number of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.
Percentage of patients readmitted to the PHP team	11.5 months	The percentage of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
Percentage of patients readmitted to usual care team	11.5 months	The percentage of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.

Trial Locations

Locations (1)

UW Hospital and Clinics; 🇺🇸 Madison, Wisconsin, United States