The Impact of a Social Work Driven Transitional Care Model on Health Outcomes for At-Risk Older Adults
试验速览
- 阶段
- 不适用
- 状态
- 已完成
- 入组人数
- 740
- 试验地点
- 2
- 主要终点
- Readmissions
研究概览
简要总结
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
详细描述
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
Research Process
- Rush University Medical Center inpatients receive the Enhanced Discharge Planning Program information sheet in the Rush patient education packet.
All Rush inpatients will receive an informational sheet about the EDPP study, with an exception of pediatric and labor/delivery inpatients. The sheet will be included in the patient education packets distributed by Rush. This will make patients aware of the EDPP program before they leave the hospital and prepare them for a call once they return home. 2. Eligible patients are referred to the Enhanced Discharge Planning Program at their point of discharge via an electronic referral report through Epic.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Health Services Research
- 盲法
- None
入排标准
- 年龄范围
- 65 Years 至 —（Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Must meet all the following criteria:
- •English speaking
- •Returning home after discharge
- •7+ medication prescribed
- •Must also meet one additional criterion:
- •Lives alone
- •Without a source of emotional support
- •Without a support system for care in place
- •Discharged with a service referral
- •High risk for falls
- •Inpatient hospitalization within 12 months
- •Identified in depth psychosocial need
- •High risk medication prescribed
排除标准
- •Primary diagnosis of transplant
- •Non-English speaking
- •Discharged to a facility
结局指标
主要结局
Readmissions
时间窗: 180 days
Readmission to hospital within 180 days of index discharge date
次要结局
- Mortality(30 days)
- Patient needs(30 days)
- Stress(30 days)
- Physician follow-up(30 days)
研究者
Robyn Golden
Associate Vice President
Rush University Medical Center