My Bridge (Mi Puente), a care transitions intervention for Hispanics/Latinos with multimorbidity and behavioral health concerns: protocol for a randomized controlled trial

Abstract

Background: Multimorbidity affects four of ten US adults and eight of ten adults ages 65 years and older, and frequently includes both cardiometabolic conditions and behavioral health concerns. Hispanics/Latinos (hereafter, Latinos) and other ethnic minorities are more vulnerable to these conditions, and face structural, social, and cultural barriers to obtaining quality physical and behavioral healthcare. We report the protocol for a randomized controlled trial that will compare Mi Puente (My Bridge), a cost-efficient care transitions intervention conducted by a specially trained Behavioral Health Nurse and Volunteer Community Mentor team, to usual care or best-practice discharge approaches, in reducing hospital utilization and improving patient reported outcomes in Latino adults with multiple cardiometabolic conditions and behavioral health concerns. The study will examine the degree to which Mi Puente produces superior reductions in hospital utilization at 30 and 180 days (primary aim) and better patient-reported outcomes (quality of life/physical health; barriers to healthcare; engagement with outpatient care; patient activation; resources for chronic disease management), and will examine the cost effectiveness of the Mi Puente intervention relative to usual care.

Methods: Participants are enrolled as inpatients at a South San Diego safety net hospital, using information from electronic medical records and in-person screenings. After providing written informed consent and completing self-report assessments, participants randomized to usual care receive best-practice discharge processes, which include educational materials, assistance with outpatient appointments, referrals to community-based providers, and other assistance (e.g., with billing, insurance) as required. Those randomized to Mi Puente receive usual-care materials and processes, along with inpatient visits and up to 4 weeks of follow-up phone calls from the intervention team to address their integrated physical-behavioral health needs and support the transition to outpatient care.

Discussion: The Mi Puente Behavioral Health Nurse and Volunteer Community Mentor team intervention is proposed as a cost-effective and culturally appropriate care transitions intervention for Latinos with multimorbidity and behavioral health concerns. If shown to be effective, close linkages with outpatient healthcare and community organizations will help maximize uptake, dissemination, and scaling of the Mi Puente intervention.

Trial registration: ClinicalTrials.gov: NCT02723019. Registered on 30 March 2016.

Keywords: Clinical trial; Health behavior; Hispanic Americans; Mental health; Multimorbidity; Patient readmission; Transitional care.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1

Conceptual overview of Mi Puente intervention. Behavioral health nurse and volunteer community mentor provide bridging support, which is enhanced by strong relationships between inpatient facility and community partners in order to achieve reduced hospital utilization and improved patient-reported outcomes

Fig. 2

Theoretical mapping of Mi Puente. Using the transtheoretical model (TTM) to assess readiness for change, and targeting resources and supports for self-management (RSSM) components 1–3 (behavioral health nurse (BHN)) and 4–6 (volunteer community mentor), the Mi Puente intervention will increase resources and decrease barriers across multiple socioecological levels. The operationalization of all RSSM components in intervention content is monitored using behavioral health nurse “Ready, Set, Action” forms and volunteer community mentor checklists (See Additional file 1). Primary outcomes (d, e) and proposed mechanisms (a–c) are operationalized with the following measures: (a) Patient Activation Measure, (b) Chronic Illness Resources Survey, (c) measure adapted from the Hispanic Community Health Study/Study of Latinos, (d) hospital utilization assessed by electronic medical record (EMR) and self-report, (e) Patient-Reported Outcomes Measurement Information System (PROMIS) General Health Scale. SEM Social-ecological model

Fig. 3

Theoretical mapping of Mi Puente. Using the transtheoretical model (TTM) to assess readiness for change, and targeting resources and supports for self-management (RSSM) components 1–3 (behavioral health nurse (BHN)) and 4–6 (volunteer community mentor), the Mi Puente intervention will increase resources and decrease barriers across multiple socioecological levels. The operationalization of all RSSM components in intervention content is monitored using behavioral health nurse “Ready, Set, Action” forms and volunteer community mentor checklists (See Additional file 1). Primary outcomes (d, e) and proposed mechanisms (a–c) are operationalized with the following measures: (a) Patient Activation Measure, (b) Chronic Illness Resources Survey, (c) measure adapted from the Hispanic Community Health Study/Study of Latinos, (d) hospital utilization assessed by electronic medical record (EMR) and self-report, (e) Patient-Reported Outcomes Measurement Information System (PROMIS) General Health Scale. SEM Social-ecological model