Post-Acute Physician Home Visit Program

Post-Acute Physician Home Visits: A Randomized Controlled Trial

New or worsening symptoms following discharge from the hospital likely leads to unplanned readmission. These rates are higher than desired and costly to patients, payers, and providers. Many interventions have unsuccessfully attempted to reduce readmissions, but few have provided in-home personnel to patients transitioning from acute care back to ambulatory care. Still fewer have involved a physician in the home. We therefore will test the effect of a physician home visit to a patient's home who was discharged in the last 4 days.

Study Overview

• Status: Completed
• Conditions: A Patient Discharged From an Acute-care Hospital Who Had an Acute Illness
• Intervention / Treatment: Other: Home visit

• Study Type: Interventional
• Enrollment (Actual): 51
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Brigham and Women's Hospital
    • Boston, Massachusetts, United States, 02130
      • Brigham and Women's Faulkner 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:

• Resides within either a 5-mile or 20-minute driving radius of Brigham and Women's Hospital (BWH) or Brigham and Women's Faulkner Hospital (BWFH) emergency room
• Has capacity to consent to study
• >=18 years old

Exclusion Criteria:

• Undomiciled
• In police custody
• Domestic violence screen positive

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Home visit; A participant in this arm will receive a home visit after discharge from the hospital.	Other: Home visit; The visit will be entirely patient tailored, last approximately one hour, and at a minimum will entail: Medical assessment; Psychosocial assessment; Medication reconciliation; Follow-up of inpatient primary team's specific recommendations; Follow-up, as needed, with primary care team or inpatient team
No Intervention: Usual Care; A participant in this arm will not receive a home visit after discharge from the hospital.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
New or worsening symptoms	"Since you got home from the hospital, have you had any symptoms at all?" If no, stop. If yes, continue. "I'm going to read off a list of symptoms, and I want you to tell me if that symptom is new or has gotten worse since you left the hospital. Please don't include symptoms that have stayed the same since you were in the hospital." For each affirmative, double check if the symptom is new or has gotten worse since getting out of the hospital. Only if new or worse, mark yes.	30 days after discharge from hospital

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
3-item Care Transition Measure, score		30 days after discharge
Total cost, 30-days post discharge		Day of discharge to 30 days later
Total reimbursement, 30-days post discharge		Day of discharge to 30 days later
Primary care provider follow-up within 14 days, y/n		Day of discharge to 14 days later
Ability to carry out the discharge plan, score	I would like to ask you about some more problems that you might have faced after you left the hospital one month ago. I will read some statements and ask if you agree or disagree.	30 days after discharge
Change in medication list due to home visit, y/n	Physician-initiated medication change during home visit	Day of home visit
Receipt of prescribed medicines following discharge, y/n	Pharmacy confirmation	30 days after discharge
Unplanned 30-day readmission(s) after index hospitalization, y/n		30 days after discharge
Unplanned 30-day readmission(s) after index hospitalization, #		30 days after discharge

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Global satisfaction with care, score	Exploratory	30 days after discharge
Days at home since discharge, #	Exploratory	30 days after discharge
All-cause 30-day readmission(s) after index hospitalization, y/n	Exploratory	30 days after discharge
All-cause 30-day readmission(s) after index hospitalization, #	Exploratory	30 days after discharge
Emergency Department (ED) observation stay(s) after index hospitalization, y/n	Exploratory	30 days after discharge
Emergency Department (ED) observation stay(s) after index hospitalization, #	Exploratory	30 days after discharge
Emergency Department (ED) visit(s) after index hospitalization, #	Exploratory	30 days after discharge
Emergency Department (ED) visit(s) after index hospitalization, y/n	Exploratory	30 days after discharge
Imaging, #	Exploratory	30 days after discharge
Imaging, y/n	Exploratory	30 days after discharge
Lab orders, #	Exploratory	30 days after discharge
Lab orders, y/n	Exploratory	30 days after discharge
Physician visits, y/n	Exploratory	30 days after discharge
Physician visits, #	Exploratory	30 days after discharge
Home health utilization, days	Exploratory	30 days after discharge
Home health utilization, y/n	Exploratory	30 days after discharge
All cause 30-day mortality, y/n	Exploratory	30 days after discharge
Unplanned 30-day mortality, y/n	Exploratory	30 days after discharge
Change in medication list due to error at discharge, y/n	Exploratory	Visit date
Pneumococcal vaccination if appropriate, y/n	Exploratory	30 days after discharge
Influenza vaccination if appropriate, y/n	Exploratory	30 days after discharge
Smoking cessation counseling if appropriate, y/n	Exploratory	30 days after discharge
Evaluation of ejection fraction as assessed by echocardiogram or other appropriate study, scheduled or completed, if not done within 1 year; y/n	Heart failure patients only; Exploratory; appropriate studies include cardiac magnetic resonance imaging, radionuclide ventriculography, single photon emission computed tomography myocardial perfusion imaging, or left ventriculography	30 days after discharge
Angiotensin converting enzyme inhibitor or angiotensin receptor blocker for heart failure with reduced ejection fraction (ejection fraction < 40%), y/n	Heart failure patients only; Exploratory	30 days after discharge
Beta blocker for heart failure with reduced ejection fraction (ejection fraction < 40%), y/n	Heart failure patients only; Exploratory	30 days after discharge
Aldosterone antagonist for heart failure with reduced ejection fraction (ejection fraction < 40%), y/n	Heart failure patients only; Exploratory	30 days after discharge
Lipid lowering for coronary artery disease, peripheral vascular disease, cerebrovascular accident, or diabetes, y/n	Heart failure patients only; Exploratory	30 days after discharge
Smoking status post-discharge	Heart failure patients only; Exploratory	30 days after discharge
Use of inappropriate medications in the elderly, y/n	Exploratory; using Screening Tool of Older Persons' potentially inappropriate Prescriptions (STOPP) and Beers criteria	30 days after discharge
Time between discharge and visit, days	Exploratory	Date of home visit
Duration of physician visit, minutes	Exploratory	Date of home visit

Collaborators and Investigators

• Sponsor: Brigham and Women's Hospital
• Investigators: Principal Investigator: Jeffrey Schnipper, MD MPH, Brigham and Women's Hospital

Publications and helpful links

General Publications

• Epstein K, Juarez E, Loya K, Gorman MJ, Singer A. Frequency of new or worsening symptoms in the posthospitalization period. J Hosp Med. 2007 Mar;2(2):58-68. doi: 10.1002/jhm.170.
• Boling PA. Care transitions and home health care. Clin Geriatr Med. 2009 Feb;25(1):135-48, viii. doi: 10.1016/j.cger.2008.11.005.
• Meyer GS, Gibbons RV. House calls to the elderly--a vanishing practice among physicians. N Engl J Med. 1997 Dec 18;337(25):1815-20. doi: 10.1056/NEJM199712183372507.
• Wong FK, Chow SK, Chan TM, Tam SK. Comparison of effects between home visits with telephone calls and telephone calls only for transitional discharge support: a randomised controlled trial. Age Ageing. 2014 Jan;43(1):91-7. doi: 10.1093/ageing/aft123. Epub 2013 Aug 26.
• Branowicki PM, Vessey JA, Graham DA, McCabe MA, Clapp AL, Blaine K, O'Neill MR, Gouthro JA, Snydeman CK, Kline NE, Chiang VW, Cannon C, Berry JG. Meta-Analysis of Clinical Trials That Evaluate the Effectiveness of Hospital-Initiated Postdischarge Interventions on Hospital Readmission. J Healthc Qual. 2017 Nov/Dec;39(6):354-366. doi: 10.1097/JHQ.0000000000000057.
• Wolff JL, Meadow A, Boyd CM, Weiss CO, Leff B. Physician evaluation and management of Medicare home health patients. Med Care. 2009 Nov;47(11):1147-55. doi: 10.1097/MLR.0b013e3181b58e30.

Study record dates

Study Major Dates

• Study Start (Actual): June 6, 2017
• Primary Completion (Actual): January 20, 2018
• Study Completion (Actual): January 20, 2018

Study Registration Dates

• First Submitted: June 5, 2017
• First Submitted That Met QC Criteria: June 5, 2017
• First Posted (Actual): June 7, 2017

Study Record Updates

• Last Update Posted (Actual): August 13, 2019
• Last Update Submitted That Met QC Criteria: August 9, 2019
• Last Verified: August 1, 2019

More Information

Terms related to this study

• Other Study ID Numbers: P000719

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No