Evaluation of a Hospital Discharge Clinic to Improve Care Coordination and Reduce Rehospitalization in Low Income Adults

Not Applicable

Completed

Interventions: Other: Federally Qualified Health Center
Other: Northwestern Follow Up Care Coordination

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.

Recruitment & Eligibility

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

Arm && Interventions

Group	Intervention	Description
Federally Qualified Health Center	Federally Qualified Health Center	Each patient is provided with information by telephone and mail, offering assistance to receive a follow-up appointment at a nearby Federally Qualified Health Center.
Northwestern Follow Up Care Coordination	Northwestern Follow Up Care Coordination	Each patient is provided with information by telephone and mail, offering assistance to receive a follow-up appointment at the Northwestern Transitional Care Follow Up Clinic.

Primary Outcome Measures

Name	Time	Method
90-Day Re-hospitalization or Death	90 days	90-day re-hospitalization (Emergency Department and/or inpatient admission) or death

Secondary Outcome Measures

Name	Time	Method
Usual Source of Primary Care	6 months	Patient report of being seen in a usual source of primary medical care 6 months after discharge
180-Day Re-hospitalization or Death	180 days	180-day re-hospitalization (Emergency Department and/or inpatient admission) or death
365-Day Re-hospitalization or Death	365 days	365-day re-hospitalization (Emergency Department and/or inpatient admission) or death
Intervention Cost	12 months	This is an evaluation of the incremental costs to implement and sustain standard Northwestern Transitional Follow Up team care, as well as the enhanced standard + health advocate personnel model
30-Day Re-hospitalization or Death	30 days	90-day re-hospitalization (Emergency Department and/or inpatient admission) or death
Health Advocate Effect	12 months	This evaluation will determine if being offered support of a novel care team member known as a "health advocate" (a form of care navigator who will assist patients to overcome social determinants of readmission) is more likely to prevent hospital readmission than receiving the standard Northwestern Transitional Follow Up Care team intervention alone.

Locations (1): Northwestern Memorial Hospital
🇺🇸
Chicago, Illinois, United States