Coordinated Emergency Department Transitions

PartnerED Care: Coordinated Emergency Department Transitions for Assisted Living Patients With Alzheimer's Disease and Related Dementias

The goal of this observational study is to learn the feasibility, acceptability, appropriateness, and adherence to a case management intervention. PartnerED is a case management intervention that aims to reduce unnecessary hospital admissions by providing real-time, structured information and discharge support to emergency department providers via phone and fax. The intervention is led by chronic care managers employed by Bluestone Accountable Care Organization, a physician group primarily serving patients in assisted living centers.

Study Overview

• Status: Completed
• Conditions: Alzheimer Disease or Associated Disorder
• Intervention / Treatment: Behavioral: Structured case management

Detailed Description

PartnerED is a case management intervention that aims to reduce unnecessary hospital admissions by providing real-time, structured information and discharge support to emergency department providers via phone and fax. The intervention is led by chronic care managers employed by Bluestone Accountable Care Organization, a physician group primarily serving patients in assisted living centers.

• Study Type: Interventional
• Enrollment (Actual): 1376
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Nebraska
    • Omaha, Nebraska, United States, 68154
      • Bluestone Accountable Care Organization

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Bluestone Accountable Care Organization patient
• Registration in emergency department between November 1, 2023 and June 30, 2024, as recorded in electronic admission, discharge, and transfer notifications

Exclusion Criteria:

• None

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: All patients with eligible emergency department visits; Eligible emergency department visits were identified using electronic admission, discharge, and transfer notifications	Behavioral: Structured case management; When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of Eligible Emergency Department Visits With Completed Outreach	Percent of eligible emergency department visits in which a case manager provided structured clinical and discharge support information to a emergency department provider about a patient who was in their care, with the goal of avoiding an unnecessary hospitalization	Within 1-3 hours of emergency department registration

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percent of Successful Outreach Conversations in Which Staff Reported Avoidance of an Unnecessary Hospitalization	Case manager self-report of whether she/he was successful in avoiding an unnecessary hospitalization of a patient after providing structured clinical and discharge support information to the emergency department provider	Within 24 hours of emergency department registration

Collaborators and Investigators

• Sponsor: Brown University
• Collaborators: National Institute on Aging (NIA)
• Investigators: Principal Investigator: Ellen McCreedy, PhD, MPH, Brown University

Study record dates

Study Major Dates

• Study Start (Actual): October 4, 2024
• Primary Completion (Actual): February 18, 2025
• Study Completion (Actual): March 30, 2025

Study Registration Dates

• First Submitted: March 30, 2025
• First Submitted That Met QC Criteria: April 16, 2025
• First Posted (Actual): April 18, 2025

Study Record Updates

• Last Update Posted (Actual): May 27, 2026
• Last Update Submitted That Met QC Criteria: May 1, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: feasibility; emergency department; case management
• Additional Relevant MeSH Terms: Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Mental Disorders; Pathologic Processes; Disease Attributes; Neurocognitive Disorders; Dementia; Tauopathies; Neurodegenerative Diseases; Pathological Conditions, Signs and Symptoms; Emergencies; Alzheimer Disease
• Other Study ID Numbers: U54AG063546_Pilot Cycle 5A; U54AG063546 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: Data use agreements do not allow for sharing individual participant data

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No