The Care Transitions Intervention

University of Colorado, Denver1 site in 1 country1,400 target enrollmentSeptember 2002

ConditionsContinuity of Patient Care

Overview

Phase: Not Applicable
Intervention: Not specified
Conditions: Continuity of Patient Care
Sponsor: University of Colorado, Denver
Enrollment: 1400
Locations: 1
Primary Endpoint: Rehospitalization rate at 30, 90 and 180 days after index hospitalization.
Status: Completed
Last Updated: 10 years ago

Overview Investigators Eligibility Criteria Outcomes Sites Similar Trials

Overview

Brief Summary

This intervention tests whether encouraging older patients and their caregivers to assert a more active role in their care transitions could improve clinical outcomes. Patients are supported by a nurse transition coach and specific tools, including a Personal Health Record.

Detailed Description

See above.

Registry

clinicaltrials.gov

Start Date

September 2002

End Date

August 2003

Last Updated

10 years ago

Study Type

Interventional

Study Design

Single Group

Sex

All

Investigators

Sponsor

University of Colorado, Denver

Responsible Party

Sponsor

Eligibility Criteria

Inclusion Criteria

•To be eligible for this study, patients from the participating delivery system had to: 1) be age 65 years or older, 2) be admitted to one of the participating delivery system's contract hospitals during the study period for a non-psychiatrically-related condition, 3) be community-dwelling (i.e., not from a long-term care facility), 4) reside within a predefined geographic radius of the hospital (thereby making a home visit feasible), 5) have a working telephone, 6) be English-speaking, 7) show no documentation of dementia in the medical record, 8) have no plans to enter hospice, 9) not be participating in another research protocol, and 10) have documented in their medical record at least one of 11 diagnoses, including stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, or pulmonary embolism.

Exclusion Criteria

•Those who did not meet the inclusion criteria.

Outcomes

Primary Outcomes

Rehospitalization rate at 30, 90 and 180 days after index hospitalization.

Secondary Outcomes

Rehospitalization rate at 30, 90 and 180 days after index hospitalization. Rehospitalization for the same condition as the index hospital stay, at 30, 90 and 180 days.