Implementation and Evaluation of A Health Innovation to Support Medicaid-Insured Individuals Following Hospitalization

Implementation and Evaluation of THRIVE: A Health Innovation to Support Care Transitions for Medicaid-Insured Individuals Following Hospitalization

The goal of this stepped wedge pragmatic trial is to compare referral patterns and post discharge outcomes in Medicaid insured individuals discharge following a hospitalization]. The aims are to 1) evaluate the implementation of the THRIVE clinical pathway, including feasibility, appropriateness, and acceptability and 2) examine referral patterns, 30- day readmission and Emergency Department (ED) utilization patterns for participants who receive THRIVE support services. During hospitalization participants will receive a referral to home care services and will be seen by a home care nurse within 48 hours following discharge. A discharging physician or Advanced Practice Provider will maintain clinical oversight for 30 days or until the patient sees primary care provider or specialist. A Care Coordination Team conducts weekly case conferences to ensure social and health needs are being addressed for 30 days post-discharge. Researchers will compare Medicaid insured patients discharged during the study, to those receiving usual care to determine if there are differences in post-acute utilization outcomes.

Study Overview

• Status: Enrolling by invitation
• Conditions: Care Transitions
• Intervention / Treatment: Behavioral: THRIVE Intervention

Detailed Description

This is a prospective single site Type 1 hybrid effectiveness-implementation parallel mixed methods (QUANT + qual) quasi-experimental study. This study design involves simultaneous collection and analysis of quantitative and qualitative data, giving priority weight to the quantitative data to evaluate program referrals, outcomes, and program fidelity, while qualitative data will evaluate process through detailed descriptions of perspectives of barriers and facilitators faced by health care providers in implementing the THRIVE intervention. Qualitative interviews will also assess stakeholder perspectives of the value of the intervention in addressing health inequities among Medicaid insured individuals cared for in the acute and home care settings. Nesting the qualitative interview within a single-site randomized trial of a the THRIVE intervention will allow us to determine whether the intervention improved primary outcomes (referrals to homecare, 30-day readmission, ED utilization, connection to PCP) and to identify professional and organizational barriers to implementation. Combining these insights with that of effectiveness outcome date will allow consideration for meaningful contextual factors that are viewed as critical to the implementation of THRIVE and subsequent outcomes. Our stepped wedge design with include a randomized roll-out to case managers at Pennsylvania Hospital and the study will be carried out over 18 months. To begin, 5 case managers will be randomized to receive training on the THRIVE clinical pathway. Following training they will be invited to begin offering referrals to the THRIVE clinical pathway. After 2 months the remaining 4 case managers will be trained on the THRIVE intervention and will be able to begin submitting referrals.

• Study Type: Interventional
• Enrollment (Estimated): 267
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Pennsylvania
    • Philadelphia, Pennsylvania, United States, 19107
      • Pennsylvania Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 99 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Medicaid insured
• Residing in the state of Pennsylvania
• Experienced a hospitalization at study hospital
• Agrees to home care at partner home care setting.

Exclusion Criteria:

• Individuals under age 18

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: THRIVE Intervention; 1 month intensive post discharge case management and care coordination.	Behavioral: THRIVE Intervention; The THRIVE Clinical Pathway is a standardized transitional care clinical pathway that supports Medicaid insured or Medicaid eligible individuals following hospitalization.
No Intervention: Usual Care; Discharge to home without intensive post acute case management or care coordination.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rates of Referrals to Homecare	We will evaluate changes in home care referrals between case managers exposed to the intervention compared to those who were not.	Through study completion, an average of 18 months
Rates of Readmissions	We will evaluate the rate of readmissions over the course of the study for THRIVE participants compared to those receiving usual care.	30 days following hospital discharge
Rates of Emergency Department Visit	We will evaluate the rate of ED visits over the course of the study for THRIVE participants compared to those receiving usual care.	30 days following hospital discharge
Primary Care or Specialist Visit	We will compare the rates of primary care provider and specialist visits within 30 days following discharge compared to those receiving usual care.	30 Days following hospital discharge

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Feasibility, Acceptability, Appropriateness, Workload	We will conduct interviews of clinicians at the conclusion of the study to gather perceptions of the THRIVE clinical pathway and facilitators and barriers to engaging with the intervention.	Through study completion, an average of 18 months

Collaborators and Investigators

• Sponsor: University of Pennsylvania
• Collaborators: Rita & Alex Hillman Foundation
• Investigators: Principal Investigator: Margo B Brooks Carthon, PhD RN, University of Pennsylvania

Publications and helpful links

General Publications

• Brom H, Henderson J, Bettencourt AP, Babe E, Brooks Carthon JM. Association of intervention fidelity and outcomes in implementation of the Thrive transitional care program for Medicaid-insured individuals. J Hosp Med. 2026 Jul 3. doi: 10.1002/jhm.70388. Online ahead of print.
• Brom H, Golinelli D, Grantham-Murillo M, Harhay MO, Chittams J, Clark R, Vyas K, Miles D, Brooks Carthon JM. A Stepped-Wedge Cluster-Randomized Trial to Increase Home Health Referrals for Medicaid-Insured Patients: The Thrive Trial. J Gen Intern Med. 2026 Apr 29. doi: 10.1007/s11606-026-10468-6. Online ahead of print.
• Brooks Carthon JM, Brom H, Grantham-Murrillo M, Sliwinski K, Mason A, Roeser M, Miles D, Garcia D, Bennett J, Harhay MO, Flores E, Amenyedor K, Clark R. Equity-Centered Postdischarge Support for Medicaid-Insured People: Protocol for a Type 1 Hybrid Effectiveness-Implementation Stepped Wedge Cluster Randomized Controlled Trial. JMIR Res Protoc. 2024 Mar 26;13:e54211. doi: 10.2196/54211.

Study record dates

Study Major Dates

• Study Start (Actual): March 27, 2023
• Primary Completion (Estimated): September 30, 2026
• Study Completion (Estimated): September 30, 2026

Study Registration Dates

• First Submitted: January 19, 2023
• First Submitted That Met QC Criteria: February 1, 2023
• First Posted (Actual): February 6, 2023

Study Record Updates

• Last Update Posted (Actual): July 16, 2026
• Last Update Submitted That Met QC Criteria: July 14, 2026
• Last Verified: July 1, 2026

More Information

Terms related to this study

• Other Study ID Numbers: 10080229

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