- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT05245773
MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care (MORE-PC)
Study Overview
Status
Conditions
Intervention / Treatment
Detailed Description
Background:
Current models of post-discharge care management are time and labor intensive, limited in scope, and inconvenient from the patient perspective, particularly when they have a need arise. Automation can significantly scale up patient touches while reserving staff time for concrete patient needs. Text messaging has been shown to enhance patient engagement (as compared to calls) in many settings, possibly due to greater convenience and the potential for asynchronous interaction. We believe using automated text messaging messaging as the foundation of a post-discharge, primary care based care management program can increase patient engagement, allow for earlier and more frequent identification of needs, and improve post-discharge outcomes.
Objective:
To evaluate the impact of a 30-day post-discharge intervention using an automated SMS platform in addition to usual care as compared to usual care alone in a multi-clinic, pragmatic randomized controlled trial on acute care utilization, post-discharge follow-up appointment scheduling and show-rates, overall patient engagement, and overall patient-clinic encounters.
Description of Intervention:
The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team. After enrollment, patients will receive an initial message asking them if they have a follow up appointment within the next 2 weeks. If they respond no, the practice will be notified to reach out and help them schedule an appointment.
Beginning the day after this introductory message, patients will receive check-in messages on a tapering schedule over the course of 30 days. For the first week they will receive 3 total messages (Monday, Wednesday and Friday); the second week they will receive a total of 2 messages (Tuesday and Thursday). For the last 2 weeks they will receive weekly messages (on Tuesdays). If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call. Patients will be able to reach out at any time throughout the 30 days by sending a message to the same number, and they will be entered into the same pathway. For any escalated need, patients will receive a follow up phone call within 1 business day. Patients who do not respond to 3 consecutive messages will receive an additional check in message ensuring that they still want to be enrolled.
Study Type
Enrollment (Actual)
Phase
- Not Applicable
Contacts and Locations
Study Locations
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Pennsylvania
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Philadelphia, Pennsylvania, United States, 19104
- University of Pennsylvania School of Medicine
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Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- The study subjects will be medium to high risk (UPHS risk score 4 and above; an internally developed and validated score assessing a patient's risk for readmission) adult (age ≥ 18) patients of the Penn Primary Care Practices who are discharged home from acute inpatient care in the broad Philadelphia region as identified in HealthShare Exchange (HSX) reports
Exclusion Criteria:
- This study will exclude discharges who do not meet criteria for transitional care management. These criteria include discharges after 1) planned chemotherapy admissions; 2) certain scheduled surgeries, including spinal surgery, joint replacements, gastric bypass, transurethral resection of the prostate, gynecologic surgeries, and transplants; 3) obstetrics admissions.
- We will exclude patients from re-enrollment during the study period (once they have been enrolled once, they will not be enrolled again). We will also exclude patients being discharged to home hospice.
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Experimental: 30-day automated hovering + usual care
The intervention arm will get the usual post-discharge call from their practice, typically within 2 business days of discharge.
In addition, they will be enrolled in the 30-day automated texting program, wherein they will receive check-in messages on a tapering schedule; they will be free to opt out at any time.
They can also message into the platform at any time.
Any needs identified through the platform will be escalated to their primary care practice, and they will receive a follow-up phone call from practice staff to address their needs.
|
The intervention will consist of automated text messages on a tapering schedule over the course of 30 days post-discharge, with responses escalated back to the practice care management team.
After initial enrollment messages, patients will receive check-in messages on a tapering schedule over the course of 30 days.
For the first week they will receive 3 total messages; the second week they will receive a total of 2 messages.
For the last 2 weeks they will receive weekly messages.
If a patient need is identified, the request will be escalated to the practice (triaged by the care management RN) for a follow up phone call.
Patients will be able to reach out at any time by sending a message to the same number, and they will be entered into the same pathway.
For any escalated need, patients will receive a follow up phone call from the practice staff.
Other Names:
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No Intervention: Usual care
The control arm will continue to receive the usual post-discharge call from their practice, typically within 2 business days of discharge.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Post-discharge acute care utilization
Time Frame: 30 days post-discharge
|
A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
|
30 days post-discharge
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Post-discharge days in the hospital
Time Frame: 30 days post-discharge
|
A continuous measure of total days spent in the hospital (in the ED or as an inpatient) after hospital discharge
|
30 days post-discharge
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Post-discharge acute care utilization
Time Frame: 7 and 60 days post-discharge
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A composite, binary measure indicating whether a patient visited the ED or was readmitted to inpatient care after discharge from the hospital.
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7 and 60 days post-discharge
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Post-discharge ED visit
Time Frame: 7, 30, and 60 days post-discharge
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A binary measure indicating whether a patient visited the ED after hospital discharge
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7, 30, and 60 days post-discharge
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Readmission
Time Frame: 7, 30, and 60 days post-discharge
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A binary measure indicating whether a patient was readmitted after hospital discharge
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7, 30, and 60 days post-discharge
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Time from discharge to first acute care visit
Time Frame: 30 days post-discharge
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A continuous measure of the time from discharge to either first ED visit or readmission
|
30 days post-discharge
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Post-discharge follow up visit
Time Frame: 14 days post-discharge
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A binary measure indicating scheduling and completion of a follow up visit with the primary care practice
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14 days post-discharge
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Number of patient-practice interactions
Time Frame: 30 days post-discharge
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A continuous measure of non-visit interactions between the patient and practice (which will include a) telephone encounters [which are the end point of any needs identified through the automated messaging program] and b) EMR portal messages)
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30 days post-discharge
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Collaborators and Investigators
Sponsor
Collaborators
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Actual)
Study Completion (Actual)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Actual)
Study Record Updates
Last Update Posted (Estimate)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Other Study ID Numbers
- 849348
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
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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