Improving Safety of Transitions to Skilled Nursing Care Using Videoconferencing (ECHO-CT)

November 29, 2023 updated by: Lewis Lipsitz, Beth Israel Deaconess Medical Center

AHRQ Health Services Research Projects: Making Health Care Safer in Ambulatory Care Settings and Long Term Care Facilities

This prospective cohort study seeks to determine if the ECHO-CT program, a healthcare videoconferencing program, can improve clinical outcomes while reducing cost and resource utilization when expanded to a community hospital setting. Data will be analyzed on the facility level and patient level.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

ECHO-Care Transitions is a healthcare outreach program utilizing videoconferencing technology to improve the quality and efficiency of care transitions for medically-complex elderly patients by connecting post-acute care facilities that receive BIDMC patients with a multidisciplinary BIDMC team that sends these patients following discharge. This case-control study seeks to determine if ECHO-CT can improve clinical outcomes and reduce cost and resource utilization during transitions of care in both an academic (BIDMC Boston) and community (BIDMC Needham) hospital.

Our prospective cohort study of the ECHO-CT intervention will take place in the two Boston-area hospitals, one providing tertiary care and one community-based care, in which the outcomes of patients transferred to Skilled Nursing Facilities (SNFs) associated with these hospitals will be compared to those transferred to SNFs from similar hospitals in New England. We will also be comparing outcomes from individual patients enrolled in the ECHO program to matched controls. Using a national database available from the Brown University Center for Gerontology and Healthcare Research, the outcomes of Medicare beneficiaries residing in SNFs that are participating in ECHO-CT will be compared to those in the comparison group using a difference-of-difference analytic approach. Analyses will be adjusted for potential confounders as appropriate.

In this study, the investigators also plan to measure satisfaction as well as process, utilization, cost and patient safety outcomes to determine best practices for implementing the program at a community hospital and affiliated SNFs.

Data will be obtained from the following sources:

  1. Protected health information (PHI) from resident assessment data, as well as Medicare claims and enrollment data to be obtained via a data use agreement (DUA) with the Centers for Medicare and Medicaid Services (CMS) by the Brown University Center for Gerontology and Health Care Research during years 2-3 of the study to include the following:

    1. The resident Minimum Data Set Resident Assessment (MDS) assessments. The MDS has nearly 400 data elements including cognitive function, communication/hearing problems, physical functioning, continence, psycho-social well-being, mood state, activity and recreation, diagnoses, health conditions, nutritional status, oral/dental status, skin conditions, special treatments, and medication use. The assessments are done for all patients admitted to Medicare and Medicaid certified SNFs, including enrollees in both traditional Medicare and Medicare Advantage. These data will already be housed at Brown University,Brown has an active DUA to obtain quarterly pulls of the population of MDS assessments .
    2. Medicare claims which will be used to ascertain 30-day costs, re-hospitalizations, and use of other medical services by Medicare fee for service (FFS) patients admitted to the SNFs. The data also include diagnosis fields to ascertain comorbidities.
    3. Medicare enrollment file includes demographic information such as sex and race, dates of birth and death, and various indicators of Medicare/Medicaid eligibility, Part D eligibility, and Medicare Advantage enrollment.
    4. BIDMC will collect and share ECHO-CT participating patient's social security number and health insurance claims number with Brown University. Their clinical information will be matched with control patients from the Medicare claims data to show study effect on 30-day costs, re-hospitalizations rate and patient length of stay.
  2. In addition to aggregates derived from above, facility level data will come from the Certification and Survey Provider Enhanced Reporting (CASPER) data, which are publicly available and based upon facility surveys for Medicare/Medicaid certification. They will be used in addition to data from "Nursing Home Compare and the Long Term Care: Facts on Care in the US (LTCFocus.org) websites to describe the SNFs.

  3. Intervention-specific data: Project-specific quality improvement data derived from questionnaires, staff satisfaction surveys, and structured meeting minutes will be designed and evaluated by BIDMC and Hebrew Senior Life

    1. SNF Satisfaction: Every 6 months the investigators will send a satisfaction questionnaire to the hospitals and SNFs participating in ECHO-CT to assess their views of the ECHO-CT sessions, the value of time spent, feelings of empowerment, inter-professional relationships, learning, and recommendations. All answers to the survey questions will be kept strictly confidential. This information will be used to improve the content and organization of the sessions and to develop tools for dissemination (Aim 3). The investigators will develop the satisfaction questionnaire during the first 6 months of the project, building upon our previous survey experience and literature review. Metrics to quantify the quality of transitional care will be derived from the work of Coleman et al.3 and incorporated into the questionnaire. Survey design and evaluation will be conducted by the outcome evaluation group under the leadership of Dr. Thomas Travison at Hebrew SeniorLife's Institute for Aging Research.
    2. Process assessment: The investigators will keep attendance logs to assess adherence to the ECHO-CT intervention and its changes over time. Any consistent decline in staff attendance for 2 or more weeks will be followed up by phone calls to assess barriers to participation and corrective actions will be taken. These may include changing to a more convenient time, identifying other providers who can attend instead, contacting facility administrators or medical directors for their support, and providing incentive gifts or continuing education credits In addition, during each ECHO-CT session, the hospital based team will inquire about unexpected outcomes or issues that arose during the transition process, including those related to patients already discussed. This element will allow for an ongoing technology-enabled learning platform and continuous quality improvement mechanism over the course of the proposed project. The value of the video-conferencing approach is that it creates a mutually trusting learning community in which "all teach and all learn."

Study Type

Interventional

Enrollment (Actual)

10708

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • United States
    • Massachusetts
      • Boston, Massachusetts, United States, 02215
        • Beth Israel Deaconess Medical Center

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

65 years and older (Older Adult)

Accepts Healthy Volunteers

No

Description

Facility Inclusion Criteria:

  • SNF receives approximately the middle third of referral volume (approx. 20-100 referrals/ average 40 per year)
  • SNF not so highly engaged with acute hospital that their patients are less likely to benefit from the intervention.
  • SNF affiliated with BIDMC Boston or BIDMC Needham

Facility Exclusion Criteria:

  • Has not recently participated in ECHO CT
  • Do not send anyone to ECHO CT training
  • Clinicians are unwilling to make a commitment to attend at least 75% of video conferences

Patient Selection:

ECHO-CT Group:

Inclusion Criteria: Patients that were discharged from BIDMC and admitted to skilled nursing facilities that are participating in ECHO-CT between April 2019 and March 2021.

Exclusion Criteria: Patients discharged from a hospital other than BIDMC. Patients admitted to a skilled nursing facility that is not participating in ECHO-CT.

Control Group:

Inclusion Criteria: Patients from skilled nursing facilities not participating in ECHO.

Exclusion Criteria: Patients discharged from BIDMC to one of our participating SNFs during the study period of April 2019- March 2021

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Health Services Research
  • Allocation: Non-Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Experimental: ECHO CT Intervention
Weekly video conference between hospitalist at Beth Israel and skilled nursing facilities.
Other: ECHO CT Intervention
weekly video conference between hospitalist and skilled nursing facilities
Other: Matched Non- Participating Facilities
Matched non-participating facilities
Other: Matched Non-Participating Facilities
Matched Non-Participating Facilities

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
30-Day Readmission Rates
Time Frame: 30-Days
Number of hospital readmissions over 30 day period among participating SNF sites
30-Days

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Health Care Utilization
Time Frame: up to 90 days
Includes average length of stay in the facility
up to 90 days
Health Care Cost
Time Frame: 30-days
Total 30-day Medicare costs for fee-for-service patients.
30-days

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Beth Israel Deaconess Medical Center

Collaborators

Brown University
Hebrew SeniorLife

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

September 30, 2018

Primary Completion (Actual)

August 31, 2023

Study Completion (Actual)

August 31, 2023

Study Registration Dates

First Submitted

February 3, 2019

First Submitted That Met QC Criteria

February 4, 2019

First Posted (Actual)

February 6, 2019

Study Record Updates

Last Update Posted (Actual)

November 30, 2023

Last Update Submitted That Met QC Criteria

November 29, 2023

Last Verified

November 1, 2023

More Information

Terms related to this study

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 2018P000457

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

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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