Adapted Hospital Discharge Intervention: the CONNECT Pilot (CONNECT)

Communication Outreach for Navigation and Needs-based Care Transitions (CONNECT): A Pilot Randomized Controlled Trial

Hospital discharge is a dangerous time for patients: one in five will suffer an adverse event, such as a medication error, and nearly 25% will be readmitted within 30 days. This time is even more dangerous for patients with who face communication barriers, including those with non-English language preference (NELP), low health literacy, and the elderly.

The investigators will pilot a post-discharge educational intervention to reinforce written discharge instructions (known as the After Visit Summary or AVS) using a randomized controlled trial design (2:1 intervention: control). The control group will receive current standard of care discharge education which includes a nurse reviewing their AVS and an automated call in English that allows patients to numerically select types of problems/questions that are then escalated to a nurse who should return their call within a few days. The intervention group will receive the standard of care discharge education with the AVS and an additional post-discharge educational call delivered by a registered nurse or other qualified health professional with the option to have written instructions professionally translated and sent via MyChart message--if available in their preferred language.

Study Overview

• Status: Recruiting
• Conditions: Communication Research
• Intervention / Treatment: Other: Additional post discharge phone call

• Study Type: Interventional
• Enrollment (Estimated): 60
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Kirsten Austad, MD MPH; Phone Number: 617 414-2050; Email: kirsten.austad@bmc.org
• Study Contact Backup: Name: Khushbu Patel, MA; Phone Number: 617 414-6227; Email: kfpatel@bu.edu

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02118
      • Recruiting
      • Boston Medical Center
      • Contact: Kirsten Austad, MD PhD; Phone Number: 617-414-2050

Participation Criteria

Eligibility Criteria

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

Description

Inclusion Criteria:

• Registered language in Epic (written or spoken) is Spanish, Haitian Creole, Portuguese, Cape Verdean, or Vietnamese
• Admitted to medicine team at Boston Medical Center (BMC)
• Being discharged home (to the community)

Exclusion Criteria:

• On airborne infections precautions at time of recruitment
• On C diff precautions at time of recruitment
• On suicide precautions at time of recruitment
• Nurse report of participant displaying cognitive impairment, ongoing delirium, or aggression
• Discharge observed during a prior admission

Study Plan

How is the study designed?

Design Details

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

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Educational intervention; Participants randomized into this arm will receive current hospital discharge education and an additional post-discharge educational call.	Other: Additional post discharge phone call; 24-72 hours after hospital discharge, a nurse will call participants to review the written After Visit Summary (AVS) given at discharge, including primary diagnosis, self-care instructions, emergency plan, medication changes, how and why to take medication, and scheduled follow up. These phone calls will take on average 10-15 minutes.
No Intervention: Standard of care; Participants randomized into this arm will receive current hospital discharge education.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Retention success by linguistic group	Number of enrolled participants who completed all study assessments stratified by linguistic group.	12 months
Fidelity to the intervention	The number of scheduled educations calls that were completed for participants in the intervention arm based on nursing documentation in Epic.	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Acceptability of the intervention	The Acceptability of Intervention Measure (AIM) will be completed by participants in the intervention arm to assess acceptability. It has four questions with 5 Likert responses where 1 = Completely disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, 5 = Completely agree, The range of scores from 4 to 20 with higher scores indicating greater acceptability.	12 months
Feasibility of the intervention	Feasibility will be assessed by the number of participants in the intervention arm whose educational call was language concordant based on nursing documentation in Epic.	12 months
Patient Understanding of Discharge Instruction (UDI) Scale	Assessed by a composite score of six key domains of discharge instructions (primary diagnosis, self-care instructions, return precautions, medication changes, medication indications, follow-up) as determined by physician adjudicators (1=poor, 4 = near perfect). Higher scores demonstrate better understanding.	12 months

Collaborators and Investigators

• Sponsor: Boston Medical Center
• Collaborators: National Institute on Minority Health and Health Disparities (NIMHD)
• Investigators: Principal Investigator: Kirsten Austad, MD MPH, Boston Medical Center, Family Medicine

Study record dates

Study Major Dates

• Study Start (Actual): January 16, 2026
• Primary Completion (Estimated): March 1, 2027
• Study Completion (Estimated): March 1, 2027

Study Registration Dates

• First Submitted: June 13, 2025
• First Submitted That Met QC Criteria: June 13, 2025
• First Posted (Actual): June 24, 2025

Study Record Updates

• Last Update Posted (Actual): January 20, 2026
• Last Update Submitted That Met QC Criteria: January 16, 2026
• Last Verified: January 1, 2026

More Information

Terms related to this study

• Keywords: Discharge instructions; Non-English language preference; Adapting hospital discharge
• Other Study ID Numbers: H-45822; K23MD019068-01 (U.S. NIH Grant/Contract)

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