Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 发起方
- Mayo Clinic
- 入组人数
- 1,947
- 试验地点
- 1
- 主要终点
- Rate of Readmission
研究概览
简要总结
This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Sequential
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •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)
排除标准
- •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
研究组 & 干预措施
Adult Medical Care Coordination
This group will receive adult medical care coordination following discharge from a recent hospitalization.
干预措施: Adult Medical Care Coordination (Other)
Remote Patient Monitoring
This group will receive remote patient monitoring following discharge from a recent hospitalization.
干预措施: Remote Patient Monitoring (Other)
Usual Care
The usual care group will not receive additional supportive care following discharge from a recent hospitalization beyond what is typically offered through their primary care team.
结局指标
主要结局
Rate of Readmission
时间窗: 30 days
The rate of patients revisiting the emergency department or being admitted to the hospital
次要结局
未报告次要终点
研究者
Michelle A. Lampman
Principal Investigator
Mayo Clinic