PATient Navigator to rEduce Readmissions
Overview
- Phase
- Not Applicable
- Intervention
- Not specified
- Conditions
- Chronic Obstructive Pulmonary Disease
- Sponsor
- University of Illinois at Chicago
- Enrollment
- 1029
- Locations
- 1
- Primary Endpoint
- PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
- Status
- Completed
- Last Updated
- 7 years ago
Overview
Brief Summary
Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.
Investigators
Jerry Krishnan
Professor of Medicine and Public Health; Associate Vice Chancellor for Population Health Sciences
University of Illinois at Chicago
Eligibility Criteria
Inclusion Criteria
- •Age 18 years or older on date of hospital admission
- •Hospitalized at the University of Illinois Hospital, Chicago
- •Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
- •Receive medical care on an inpatient medical service
Exclusion Criteria
- •Unable to understand and speak English
- •Unable/decline to give informed consent
- •Previous participant in PArTNER
- •Planned transfer to another acute care facility
- •Planned discharge to facility other than home (e.g. long term care facility)
- •Currently on hospice or plans to discharge home to hospice
- •Current plans to leave against medical advice
Outcomes
Primary Outcomes
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Time Frame: 30 days post discharge
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates improvement. A change equal to 0 indicates no change. A change \>0 indicates worsening.
PROMIS Informational Support (v2.0, SF4a)
Time Frame: 30 days post discharge
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Secondary Outcomes
- PROMIS Emotional Support (v2.0, SF4a)(60 days post discharge)
- PROMIS Instrumental Support (v2.0, SF4a)(60 days post discharge)
- PROMIS Global Health, Mental (v1.1, SF)(60 days post discharge)
- Re-hospitalization or Death(60 days post discharge)
- PROMIS Global Health, Physical (v1.1, SF)(60 days post discharge)
- PROMIS Emotional Distress-Anxiety (v1.0, SF4a)(60 days post discharge)
- PROMIS Informational Support (v2.0, SF4a)(60 days post discharge)
- Death(60 days post discharge)
- ED Visit, Re-hospitalization, or Death(60 days post discharge)
- Outpatient Healthcare Visit(14 days post discharge)