PATient Navigator to rEduce Readmissions (PArTNER)

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Study Overview

• Status: Completed
• Conditions: Myocardial Infarction; Heart Failure; Pneumonia; Chronic Obstructive Pulmonary Disease; Sickle Cell Disease
• Intervention / Treatment: Behavioral: Hospital usual care; Behavioral: Navigator intervention; Behavioral: Peer-led telephone support line

• Study Type: Interventional
• Enrollment (Actual): 1029
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Illinois
    • Chicago, Illinois, United States, 60612
      • University of Illinois Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Age 18 years or older on date of hospital admission
2. Hospitalized at the University of Illinois Hospital, Chicago
3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
4. Receive medical care on an inpatient medical service

Exclusion Criteria:

1. Unable to understand and speak English
2. Unable/decline to give informed consent
3. Previous participant in PArTNER
4. Planned transfer to another acute care facility
5. Planned discharge to facility other than home (e.g. long term care facility)
6. Currently on hospice or plans to discharge home to hospice
7. Current plans to leave against medical advice

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Usual Care; Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Behavioral: Hospital usual care; Written discharge instructions provided to patients prior to hospital discharge.
Experimental: Usual Care + PArTNER; Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.	Behavioral: Hospital usual care; Written discharge instructions provided to patients prior to hospital discharge.; Behavioral: Navigator intervention; A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team; Behavioral: Peer-led telephone support line; The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.	30 days post discharge
PROMIS Informational Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
PROMIS Emotional Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
PROMIS Instrumental Support (v2.0, SF4a)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
PROMIS Global Health, Physical (v1.1, SF)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
PROMIS Global Health, Mental (v1.1, SF)	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	30 days post discharge
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.	60 days post discharge
PROMIS Informational Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
PROMIS Emotional Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
PROMIS Instrumental Support (v2.0, SF4a)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
PROMIS Global Health, Physical (v1.1, SF)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
PROMIS Global Health, Mental (v1.1, SF)	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.	60 days post discharge
Death	Caregiver-reported and confirmed by EHR review	30 days post discharge
Death	Caregiver-reported and confirmed by EHR review	60 days post discharge
Re-hospitalization or Death	Confirmed by EHR review	30 days post discharge
Re-hospitalization or Death	Confirmed by EHR review	60 days post discharge
ED Visit, Re-hospitalization, or Death	Confirmed by EHR review	30 days post discharge
ED Visit, Re-hospitalization, or Death	Confirmed by EHR review	60 days post discharge
Outpatient Healthcare Visit	Self-reported	14 days post discharge
Outpatient Healthcare Visit	EHR-reported	14 days post discharge

Collaborators and Investigators

• Sponsor: University of Illinois at Chicago
• Collaborators: Patient-Centered Outcomes Research Institute; American Heart Association; University of Kentucky; Baystate Medical Center; National Jewish Health; COPD Foundation; Society of Hospital Medicine; Mended Hearts; Sickle Cell Disease Association of Illinois; AcademyHealth; The National Association of Social Workers Foundation; Respiratory Health Association; University of Illinois Sickle Cell Patient Council
• Investigators: Principal Investigator: Jerry A Krishnan, MD, PhD, University of Illinois at Chicago; Principal Investigator: Elizabeth Calhoun, PhD, University of Arizona; Principal Investigator: Mark V. Williams, MD, University of Kentucky

Publications and helpful links

General Publications

• LaBedz SL, Prieto-Centurion V, Mutso A, Basu S, Bracken NE, Calhoun EA, DiDomenico RJ, Joo M, Pickard AS, Pittendrigh B, Williams MV, Illendula S, Krishnan JA. Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study. J Gen Intern Med. 2022 Dec;37(16):4103-4111. doi: 10.1007/s11606-022-07461-0. Epub 2022 Mar 8.

Helpful Links

• Patient-Centered Outcomes Research Institute (PCORI): Funding Award details

Study record dates

Study Major Dates

• Study Start: July 1, 2014
• Primary Completion (Actual): October 1, 2016
• Study Completion (Actual): October 1, 2016

Study Registration Dates

• First Submitted: April 1, 2014
• First Submitted That Met QC Criteria: April 10, 2014
• First Posted (Estimate): April 15, 2014

Study Record Updates

• Last Update Posted (Actual): February 15, 2019
• Last Update Submitted That Met QC Criteria: October 1, 2018
• Last Verified: October 1, 2018

More Information

Terms related to this study

• Keywords: Readmissions; Patient Navigators; Peer Coaching
• Additional Relevant MeSH Terms: Ischemia; Pathologic Processes; Necrosis; Myocardial Ischemia; Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Respiratory Tract Diseases; Lung Diseases; Hematologic Diseases; Genetic Diseases, Inborn; Anemia; Anemia, Hemolytic, Congenital; Anemia, Hemolytic; Hemoglobinopathies; Myocardial Infarction; Infarction; Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Anemia, Sickle Cell
• Other Study ID Numbers: PCORI-IH 1211-4365