Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial

Not Applicable

Completed

• Conditions: Patient Activation
• Interventions: Other: Remote Patient Monitoring; Other: Adult Medical Care Coordination

• Registration Number: NCT04224220
• Lead Sponsor: Mayo Clinic

Brief Summary

This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.

Detailed Description

Not available

Study Timeline

• Study Start: 2020-01-01
• Study First Submitted: 2020-01-08
• Study First Submitted QC: 2020-01-08
• Study First Posted: 2020-01-13
• Primary Completion: 2022-07-01
• Study Completion: 2023-01-01
• Status Verified: 2023-02
• Last Update Submitted: 2023-02-13
• Last Update Posted: 2023-02-15

Recruitment & Eligibility

• Status: COMPLETED
• Sex: All
• Target Recruitment: 1947

Inclusion Criteria

• Discharged from the hospital in the past 7 days
• LACE+ score of 59 or greater and at least two chronic conditions
• Index hospitalization with discharge directly to community dwelling home (home, assisted living)
• English speaking
• Normal cognitive function - mild dementia or mild cognitive impairment is allowed if a caregiver is able to work with the care coordinator and patient during program enrollment
• Mayo Clinic or Mayo Clinic Health System provider managing the patient's care (e.g. primary care); patient is assigned to the panel of a Mayo Clinic Medical Doctor/Nurse Practitioner/Physician Assistant
• Access to and ability to communicate via telephone (either patient or caregiver)

Exclusion Criteria

• Psychiatric hospital admission
• Patients with a serious and persistent mental health disorder or severe treatment interfering behavior that require a higher level of service than is available at the patient's clinic
• Untreated active substance or alcohol abuse
• Dementia or moderate to severe cognitive impairment
• Discharged to one of the following: rehabilitation unit, skilled nursing facility, assisted living memory unit, group home
• Pregnancy
• Active treatment for cancer
• Receiving dialysis or transplant services
• Life expectancy < 6 months or enrolled in hospice or palliative care programs
• Patient is unwilling to sign a Release of Information (ROI); ROI allows those providing care, internal and external, to be actively involved in the patient's care coordination
• Patients with active tuberculosis (TB)
• Violent patient flag noted in Epic (for adult medical care coordination)
• Patient declines home visit (for adult medical care coordination)
• Patient is already enrolled in remote patient monitoring or the care transitions program

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: SEQUENTIAL

Arm && Interventions

Group	Intervention	Description
Remote Patient Monitoring	Remote Patient Monitoring	This group will receive remote patient monitoring following discharge from a recent hospitalization.
Adult Medical Care Coordination	Adult Medical Care Coordination	This group will receive adult medical care coordination following discharge from a recent hospitalization.

Primary Outcome Measures

Name	Time	Method
Rate of Readmission	30 days	The rate of patients revisiting the emergency department or being admitted to the hospital

Trial Locations

Locations (1)

Mayo Clinic; 🇺🇸 Rochester, Minnesota, United States