Care Transition Patient Experience Study With Electronic Tool

Not Applicable

• Conditions: Communication; Care Transition
• Interventions: Other: Care Connector care transition module

• Registration Number: NCT03970174
• Lead Sponsor: Trillium Health Partners

Brief Summary

Patients being admitted to hospital are becoming more complex and they often require a team of health professionals (doctors from different disciplines, nurses, and allied health professionals) working together to meet their needs. Effective communication among this team and with patients is essential to providing high quality patient-centered care. Care Connector is an electronic tool that was developed to help health professionals communicate about patient care with each other. It also incorporates best practice whenever possible (such as the used of Patient Oriented Discharge Summary \[PODS\] developed at University Health Network) during care transitions. We want to understand whether using electronic tools can address the communication issues faced by patients/families, and whether they impact on repeat visits to the Emergency Department or the hospital after discharge. In this study, we will be asking patients and families who have recently been discharged from hospital to describe their experience with communication and care transitions through a brief telephone survey. All of them will be discharged from units where Care Connector was used. However, some of the units would have used the PODS feature while others will not. A small group will also be invited to participate in an in-depth telephone interview. The results of this study will be used to improve Care Connector and to enhance communication and patient experience in general.

Detailed Description

In this mixed methods study, we examine how electronic tools impact patient/family experience of communication in hospital and care transitions from hospital to home. Care Connector is an electronic interprofessional communication and collaboration platform initially designed to address communication challenges faced by interprofessional care team. It has been augmented to support care transitions through a care transition module (that include the generation of provider-facing discharge summary and PODS). This study examines the impact of this care transition module on patient/family experience of in-hospital communication and care transitions. The quantitative component is a controlled study where baseline data is collected on 4 medicine wards. The care transition module is then introduced to 2 of the 4 medicine wards (intervention) while the other 2 (control) wards continue to operate without the explicit use of the care transition module. Data is then collected again on all 4 wards to understand impact of patient/family experience, as well as objective outcomes of ED visits and re-admission within 30 days. A number of care transition process measures will also be obtained. In the qualitative component, we will interview patients/families, as well as healthcare providers to understand how technology can or cannot address these issues.

Study Timeline

• Study Start: 2018-02-02
• Study First Submitted: 2019-05-09
• Study First Submitted QC: 2019-05-29
• Study First Posted: 2019-05-31
• Primary Completion: 2019-07-31
• Status Verified: 2020-03
• Last Update Submitted: 2020-03-10
• Last Update Posted: 2020-03-11
• Study Completion: 2020-06-30

Recruitment & Eligibility

• Status: UNKNOWN
• Sex: All
• Target Recruitment: 240

Inclusion Criteria

1. General medical patients cared for and discharged by the Hospitalist service
2. Be 18 years of age and above
3. Length of stay for hospitalization is at least 48 hours
4. The discharge destination is home (with or without support), or retirement home
5. Has the cognitive ability to, or has a substitute decision maker (SDM) (if patient is not capable) able to, provide informed consent for this research study
6. Can be contacted by telephone up to 30 days post discharge
7. Able to respond to survey questions over telephone (assistance from family member or other caregiver at the time of telephone survey is permitted)

Exclusion Criteria

1. Discharged from a non-Medicine ward (e.g. medicine patient bed spaced to a surgical ward) or from the Emergency Department directly
2. Previously participated in this study (in case of re-admission)
3. Discharge destination is another acute care facility, rehab, palliative care unit, complex continuing care, long term care, or any other facility not listed in inclusion criteria 4.
4. Died in hospital
5. Unable to give informed consent due to language barrier and lack of suitable assistance from family members and/or caregivers and/or SDM (if patient is not capable)
6. Cannot be contacted by telephone after discharge
7. Unable to respond to telephone survey questions for any reason (e.g. hearing impairment, language barrier) and lack of availability of family members and/or other caregivers willing and able to provide assistance

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Intervention	Care Connector care transition module	Two of the 4 Medicine wards will have implemented the care transition module of Care Connector

Primary Outcome Measures

Name	Time	Method
Care transition measure 3	Up to 30 days post discharge	This is a validated measure developed by Coleman et al (Med Care. 2008 Mar;46(3):317-22) to measure quality of care transitions. It contains 3 questions (please see reference for questions).

Secondary Outcome Measures

Name	Time	Method
ED visit	30 days post discharge	ED visit to any site at Trillium Health Partners
In-hospital communication	Up to 30 days post discharge	Subset of questions from the Canadian Patient Experience Survey - Inpatient Care (CPES-IC)
Presence of follow up plan in discharge summary	At the time of patient discharge (0 days)	Binary (yes/no) assessment of whether the dictated discharge summary contains a follow-up plan section.
Proportion of patients referred to community support services	At time of patient discharge (0 days)	Number of patients referred to community support services / total number of patients
Hospitalization	30 days post discharge	Hospitalization to any site at Trillium Health Partners
Proportion of appointments with date/time confirmed at discharge	At time of patient discharge (0 days)	Number of appoints with date/time confirmed / total number of appointments

Trial Locations

Locations (1)

Trillium Health Partners; 🇨🇦 Mississauga, Ontario, Canada