Addressing safety, quality and cost of care through a novel, telehealth, outpatient transitional care model to determine the impact on preventable hospitalisations in people with multimorbidity– the TTOMMI trial

The University of Adelaide0 个研究点目标入组 200 人开始时间: 2024年2月15日最近更新: 2024年2月19日

适应症

试验速览

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•Inpatients (ward or emergency department)
•Sufficient cognitive function and English language skills to provide informed consent and complete assessments
•Ability to engage in telehealth
•A history of either diabetes with cardiovascular disease, or comorbidity in at least 3 of the following illness domains:
•oDiabetes: type 1 or type 2
•oCardiovascular disease: symptomatic atherosclerotic disease (ischemic heart disease, cerebrovascular disease, peripheral vascular disease, symptomatic valvular heart disease or atrial fibrillation
•oChronic cardiac failure
•oPsychiatric illness including mood or anxiety disorders
•oRespiratory disease including chronic obstructive airways disease, asthma, or interstitial lung disease
•oKidney disease resulting in chronic renal impairment with creatinine clearance <30 ml/min
•oCurrent active malignancy.

•Patients living in or likely to be discharged to high level residential aged care facility
•Patients enrolled in a comprehensive management program on discharge, e.g., formal rehabilitation program, rehabilitation in the home, heart failure outreach service, COPD pulmonary rehabilitation, hospital in the home, or receiving disability or community psychiatric services including care coordination
•Patients followed up through other local health network (LHN) services providing community outreach such as patients who are homeless
•Patients with a current history of illicit drug or alcohol dependence which may interfere with ability to engage with the program
•Patients with palliative intent and likely to have a life expectancy of less than 6 months
•Patients due for elective readmission within 2 weeks of current hospital discharge
•Insufficient cognitive function or English language skills to provide informed consent and complete assessments.

发起方