Addressing safety, quality and cost of care through a novel, telehealth, outpatient transitional care model – the TTOMMI trial

Not Applicable

Recruiting

• Conditions: preventable hospital readmission; multimorbidity; Public Health - Health service research

• Registration Number: ACTRN12624000142538
• Lead Sponsor: The University of Adelaide

Brief Summary

Not available

Detailed Description

Not available

Study Timeline

• Results First Posted: 1900-01-01
• Study Start: 2024-02-15
• Last Update Posted: 19 February 2024

Recruitment & Eligibility

• Status: Recruiting
• Sex: All
• Target Recruitment: 200

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
oCurrent active malignancy.

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.

Study & Design

• Study Type: Interventional
• Study Design: Not specified

Primary Outcome Measures

Name	Time	Method
Rate of representation to hospital (emergency department or hospital admission) within 1 month of discharge from index admission[ Within 1 month of discharge from index admission]

Secondary Outcome Measures

Name	Time	Method
Evaluate the patient experience with continuity of care and the transition service (Patient Continuity of Care Questionnaire, PCCQ)[ 3 months from index admission];Assess patients’ symptom burden pre and post transitional support service intervention[ Baseline (index admission), <br>6-8 weeks post index admission <br>12 months post index admission];Evaluate patients’ quality of life, self-efficacy, and symptom management, pre and post intervention[ Baseline (index admission), <br>6-8 weeks post index admission <br>12 months post index admission];Calculate a cost/benefit analysis on the transitional service model of care[ On research completion (12 - 18 months from enrolment of first participant).]