PATient Navigator to rEduce Readmissions

Not Applicable

Completed

• Conditions: Heart Failure; Pneumonia; Chronic Obstructive Pulmonary Disease; Sickle Cell Disease; Myocardial Infarction
• Interventions: Behavioral: Hospital usual care; Behavioral: Navigator intervention; Behavioral: Peer-led telephone support line

• Registration Number: NCT02114515
• Lead Sponsor: University of Illinois at Chicago

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.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2014-04-01
• Study First Submitted QC: 2014-04-10
• Study First Posted: 2014-04-15
• Study Start: 2014-07
• Primary Completion: 2016-10
• Study Completion: 2016-10
• Results First Submitted: 2017-10-20
• Status Verified: 2018-10
• Results First Submitted QC: 2018-10-01
• Last Update Submitted: 2018-10-01
• Results First Posted: 2019-02-15
• Last Update Posted: 2019-02-15

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 1029

Inclusion Criteria

1. Age 18 years or older on date of hospital admission
2. Hospitalized at the University of Illinois Hospital, Chicago
3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
4. Receive medical care on an inpatient medical service

Exclusion Criteria

1. Unable to understand and speak English
2. Unable/decline to give informed consent
3. Previous participant in PArTNER
4. Planned transfer to another acute care facility
5. Planned discharge to facility other than home (e.g. long term care facility)
6. Currently on hospice or plans to discharge home to hospice
7. Current plans to leave against medical advice

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Usual Care	Hospital usual care	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.
Usual Care + PArTNER	Peer-led telephone support line	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Usual Care + PArTNER	Hospital usual care	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Usual Care + PArTNER	Navigator intervention	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Primary Outcome Measures

Name	Time	Method
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	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)	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 Outcome Measures

Name	Time	Method
Outpatient Healthcare Visit	14 days post discharge	EHR-reported
PROMIS Emotional Support (v2.0, SF4a)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
PROMIS Instrumental Support (v2.0, SF4a)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
PROMIS Global Health, Mental (v1.1, SF)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
ED Visit, Re-hospitalization, or Death	60 days post discharge	Confirmed by EHR review
Re-hospitalization or Death	60 days post discharge	Confirmed by EHR review
PROMIS Global Health, Physical (v1.1, SF)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 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)	60 days post discharge	Change in T-score from baseline to 60 days post discharge (60 days minus baseline).; A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Death	60 days post discharge	Caregiver-reported and confirmed by EHR review

Trial Locations

Locations (1)

University of Illinois Hospital; 🇺🇸 Chicago, Illinois, United States