Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial
Not Applicable
Completed
- Conditions
- Patient Activation
- 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
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
- 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
- Secondary Outcome Measures
Name Time Method
Related Research Topics
Explore scientific publications, clinical data analysis, treatment approaches, and expert-compiled information related to the mechanisms and outcomes of this trial. Click any topic for comprehensive research insights.
What molecular mechanisms underlie nurse-based care coordination in reducing hospital readmissions for primary care patients with low patient activation scores?
How does nurse-led remote patient monitoring compare to standard-of-care follow-up in preventing 30-day readmissions among high-risk primary care populations?
Are there specific biomarkers or patient activation metrics that predict response to nurse-based care coordination interventions in post-discharge settings?
What adverse events are associated with nurse-based remote patient monitoring programs, and how do they compare to traditional care coordination models?
How do nurse-based care coordination and remote monitoring strategies integrate with existing primary care workflows for chronic disease management?
Trial Locations
- Locations (1)
Mayo Clinic
🇺🇸Rochester, Minnesota, United States
Mayo Clinic🇺🇸Rochester, Minnesota, United States