Evaluation of a Novel Hospital Discharge Clinic to Improve Care Coordination and Reduce Rehospitalization Among Low Income Adults
Overview
- Phase
- N/A
- Intervention
- Not specified
- Conditions
- Patient Readmission
- Sponsor
- Northwestern University
- Enrollment
- 654
- Locations
- 1
- Primary Endpoint
- 90-Day Re-hospitalization or Death
- Status
- Completed
- Last Updated
- 6 years ago
Overview
Brief Summary
This randomized controlled trial examines the effects of a transitional care clinic for high-risk patients at an academic medical center who had no trusted medical home. The trial will provide the first reliable evaluation of the Northwestern Transitional Care Clinic / Follow Up Clinic's (NFC) impact on re-admissions, care coordination, and costs. This research will allow us to assess the value of the NFC and similar models of care for providing a more coordinated care approach that results in better treatment outcomes for urban poor populations.
It is hypothesized that NFC patients will have fewer 90-day re-hospitalizations and are more likely to have a usual source of primary care 6 months after discharge.
Detailed Description
The Northwestern Transitional Care Follow-up Clinic (NFC) was established in 2012 to improve the coordination of care for these patients following inpatient or Emergency Department discharge from Northwestern Memorial Hospital. Since 2012, the NFC has constructed an integrated team care approach, logging about 2000 post-discharge encounters with Medicaid or patients without insurance. The NFC model has evolved over the past 2 years in response to a need to address mental as well as physical health needs and to interface with community resources to address social determinants of health that might otherwise lead to frequent re-admission. By working with clinical partners and public payers like Medicaid and County Care, the NFC has also worked to transition patients to accessible primary care medical homes that will provide behavioral, physical, and preventive care. The current study will provide the first reliable evaluation of the clinic's impact on re-admissions, care coordination, and costs. This research will allow us to assess the value of the NFC and similar models of care for providing a more coordinated care approach that results in better treatment outcomes for urban poor populations.
Investigators
Ronald Ackermann
Senior Associate Dean for Public Health, Director, Institute for Public Health and Medicine, Professor of Medicine
Northwestern University
Eligibility Criteria
Inclusion Criteria
- •All patients eligible for Northwestern Transitional Follow Up care post-discharge from Northwestern Memorial Hospital
- •Adults (18 years of age or older)
- •Patients referred by an Northwestern Memorial Hospital care provider for discharge coordination by the Northwestern Transitional Follow Up Clinic
Exclusion Criteria
- •Individuals who are not yet adults (infants, children, teenagers)
- •Pregnant Women
- •Prisoners
Outcomes
Primary Outcomes
90-Day Re-hospitalization or Death
Time Frame: 90 days
90-day re-hospitalization (Emergency Department and/or inpatient admission) or death
Secondary Outcomes
- Usual Source of Primary Care(6 months)
- 180-Day Re-hospitalization or Death(180 days)
- 365-Day Re-hospitalization or Death(365 days)
- Intervention Cost(12 months)
- 30-Day Re-hospitalization or Death(30 days)
- Health Advocate Effect(12 months)