MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 5,000
- 试验地点
- 2
- 主要终点
- Post-discharge acute care utilization
研究概览
简要总结
This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice. The population will be patients who receive care from participating practices and are discharged from an inpatient stay. In addition to the usual phone call from their practice, patients will be randomized to enrollment in the program, wherein they will receive automated SMS messages on a tapering schedule over 30 days.
详细描述
Background:
Current models of post-discharge care management are time and labor intensive, limited in scope, and inconvenient from the patient perspective, particularly when they have a need arise. Automation can significantly scale up patient touches while reserving staff time for concrete patient needs. Text messaging has been shown to enhance patient engagement (as compared to calls) in many settings, possibly due to greater convenience and the potential for asynchronous interaction. We believe using automated text messaging messaging as the foundation of a post-discharge, primary care based care management program can increase patient engagement, allow for earlier and more frequent identification of needs, and improve post-discharge outcomes.
Objective:
To evaluate the impact of a 30-day post-discharge intervention using an automated SMS platform in addition to usual care as compared to usual care alone in a multi-clinic, pragmatic randomized controlled trial on acute care utilization, post-discharge follow-up appointment scheduling and show-rates, overall patient engagement, and overall patient-clinic encounters.
Description of Intervention:
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •The study subjects will be medium to high risk (UPHS risk score 4 and above; an internally developed and validated score assessing a patient's risk for readmission) adult (age ≥ 18) patients of the Penn Primary Care Practices who are discharged home from acute inpatient care in the broad Philadelphia region as identified in HealthShare Exchange (HSX) reports
排除标准
- •This study will exclude discharges who do not meet criteria for transitional care management. These criteria include discharges after 1) planned chemotherapy admissions; 2) certain scheduled surgeries, including spinal surgery, joint replacements, gastric bypass, transurethral resection of the prostate, gynecologic surgeries, and transplants; 3) obstetrics admissions.
- •We will exclude patients from re-enrollment during the study period (once they have been enrolled once, they will not be enrolled again). We will also exclude patients being discharged to home hospice.
结局指标
主要结局
Post-discharge acute care utilization
时间窗: 30 days post-discharge
A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
次要结局
- Time from discharge to first acute care visit(30 days post-discharge)
- Post-discharge follow up visit(14 days post-discharge)
- Post-discharge days in the hospital(30 days post-discharge)
- Post-discharge acute care utilization(7 and 60 days post-discharge)
- Post-discharge ED visit(7, 30, and 60 days post-discharge)
- Readmission(7, 30, and 60 days post-discharge)
- Number of patient-practice interactions(30 days post-discharge)