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Clinical Trials/ACTRN12624000142538
ACTRN12624000142538
Recruiting
未知

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 sites200 target enrollmentFebruary 15, 2024

Overview

Phase
未知
Intervention
Not specified
Conditions
preventable hospital readmission
Sponsor
The University of Adelaide
Enrollment
200
Status
Recruiting
Last Updated
2 years ago

Overview

Brief Summary

No summary available.

Registry
who.int
Start Date
February 15, 2024
End Date
TBD
Last Updated
2 years ago
Study Type
Interventional
Sex
All

Investigators

Eligibility Criteria

Inclusion Criteria

  • 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

Exclusion Criteria

  • 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.

Outcomes

Primary Outcomes

Not specified

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