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- Ensaio Clínico NCT02045147
Home Based Care Transitions Tailored by Cognition and Patient Activation
Home Based Care Transitions Tailored by Cognition and Patient Activation: A Prudent Use of Transitional Care Resources
Visão geral do estudo
Status
Condições
Descrição detalhada
One in five Medicare patients discharged from the hospital experience readmission within 30 days. Too often, hospital readmissions result from inadequate transition from hospital to home at discharge. Care transitions are complicated because of high patient acuity, multiple comorbidities, decreased length of stay, and multiple clinician involvement increasing the number of handoffs. With decreased length of stay, many patients do not comprehend or feel confident with instructions for discharge, thus management of their chronic illnesses are difficult. Most formal care transition programs are standardized and every patient receives similar strategies or interventions. However, it has been well documented that patients with cognitive problems and decreased activation are at high risk for re-hospitalization related to impaired self-management. We believe that assessment of cognition and patient activation during the patient's hospitalization will provide valuable information for discharge interventions. Data related to cognition and activation can be used to tailor discharge planning and help determine what type and how many resources are needed for individual patients after hospital discharge. The purpose of this feasibility study is to examine the effects of delivering a home based care transitions intervention (HBCTI) with four different groups tailored on cognition and level of patient activation compared to usual care (UC) on the outcomes of health care utilization (HCU) and health outcomes: patient-reported health status, assessment of care for chronic conditions, and quality of life in adult patients with multiple chronic diseases discharged to home from the hospital.
We will test our intervention with the following aims: Aim 1.To evaluate the effects of HBCTI on health care utilization. We will measure HCU (number of emergency department(ED) visits, number of unplanned clinic visits, and number of readmissions) at 1, 2, and 6 months after discharge. Our working hypothesis is that patients in the HBCTI groups compared to the UC group will have lower HCU over time (at 1, 2 and 6 months); Aim 2. To evaluate the effects of HBCTI on the following health outcomes: patient-reported health status (PROMIS-29), assessment of care for chronic conditions (PACIC), and quality of life (EuroQol). Our working hypothesis is that patients in the HBCTI groups compared to the UC group will have improved patient-reported health status, assessment of care for chronic conditions, and quality of life (EuroQol) at 1, 2, and 6 months after discharge.
The findings from this study have the potential to change this paradigm in three ways: 1) we will gain a better understanding of the role of cognition and patient activation in promoting self-management to enhance outcomes; 2). our innovative approach, which considers the unique needs of patients based on their level of cognition and patient activation will advance new concepts in care transition programs; 3) we will have a better understanding of varying intensities of visits, level of providers, and type and amount of strategies administered. This practical model for care transitions could serve as a model within the larger health care delivery system that could result in significant cost savings.
Tipo de estudo
Inscrição (Real)
Estágio
- Não aplicável
Contactos e Locais
Locais de estudo
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Nebraska
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Lincoln, Nebraska, Estados Unidos, 68510
- Saint Elizabeth Regional Medical Center
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Critérios de participação
Critérios de elegibilidade
Idades elegíveis para estudo
Aceita Voluntários Saudáveis
Gêneros Elegíveis para o Estudo
Descrição
Inclusion Criteria:
- Adult Patients (age 19 and older) being discharged from the hospital with three or more chronic diseases;
- Have a score greater than 17 on the Montreal Cognitive Assessment (dementia);
- Reside within a 35 mile radius of Lincoln, Ne.; and
- Able to hear, speak and read English.
Exclusion Criteria:
Patients will be excluded if they:
- have a terminal illness;
- have a score of less than 17 on the Montreal Cognitive Assessment (dementia);
- are under the care of The Physicians Network (TPN) at St. Elizabeth Regional Medical Center (SERMC).
Plano de estudo
Como o estudo é projetado?
Detalhes do projeto
- Finalidade Principal: Tratamento
- Alocação: Randomizado
- Modelo Intervencional: Atribuição Paralela
- Mascaramento: Nenhum (rótulo aberto)
Armas e Intervenções
Grupo de Participantes / Braço |
Intervenção / Tratamento |
---|---|
Experimental: Grp 1 Low Cognition, Low Activation
Group 1: Subjects will receive an 8 week care transition intervention with an Advanced Practice Registered Nurse-Nurse Practitioner (APRN-NP) and Certified Nursing Assistant (CNA).
The APRN-NP will guide the care transition intervention.
This group will receive the most intense intervention.
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The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider.
Education is provided at a 5th grade reading level.
The "teach back" method is used to validate knowledge, skills and confidence.
Once knowledge is validated, the interventions focused on motivation.
Outros nomes:
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Experimental: Grp 2 Low Cognition, High Activation
Group 2: Subjects will receive an 8 week care transition intervention with an APRN-NP and CNA.
The APRN-NP will guide the care transition intervention.
This group will receive an intense intervention.
|
The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider.
Education is provided at a 5th grade reading level.
The "teach back" method is used to validate knowledge, skills and confidence.
Once knowledge is validated, the interventions focused on motivation and handling stressful situations.
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Experimental: Grp 3 Normal Cognition, Low Activation
Group 3: Subjects will receive an 4 week care transition intervention with a Registered Nurse (RN) Coach.
This group will be evaluated at four weeks, if the patient activation levels are still low, they will be referred to the 4 week APRN-NP and CNA.
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The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider.
Education is provided for areas of misunderstanding.
The "teach back" method is used to validate knowledge, skills and confidence.
Interventions are focused on motivation and developing personal behavioral goals.
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Experimental: Grp 4 Normal Cognition, High Activation
Group 4: Subjects will receive the least intensive intervention delivered by a RN coach.
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The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider.
Focus is on maintaining behaviors during hardship and stress.
Empowering, motivating and validating are strategies utilized.
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O que o estudo está medindo?
Medidas de resultados primários
Medida de resultado |
Descrição da medida |
Prazo |
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Health Care Utilization
Prazo: 6 months
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Number of Emergency Department Visits and number of re-admissions to the hospital within a 6 month time period will be measured.
Validation data will be obtained from the clinical sites.
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6 months
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Medidas de resultados secundários
Medida de resultado |
Descrição da medida |
Prazo |
---|---|---|
Patient reported health status.
Prazo: 1 month, 2 months and 6 months
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Data from the patient-reported health status (PROMIS measure), assessment of care for chronic conditions, and quality of life (EQ-5D) at 1, 2, and 6 months after discharge will be measured and compared for group differences.
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1 month, 2 months and 6 months
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Colaboradores e Investigadores
Patrocinador
Investigadores
- Investigador principal: Lani M Zimmerman, PhD, University of Nebraska
Datas de registro do estudo
Datas Principais do Estudo
Início do estudo
Conclusão Primária (Real)
Conclusão do estudo (Real)
Datas de inscrição no estudo
Enviado pela primeira vez
Enviado pela primeira vez que atendeu aos critérios de CQ
Primeira postagem (Estimativa)
Atualizações de registro de estudo
Última Atualização Postada (Real)
Última atualização enviada que atendeu aos critérios de controle de qualidade
Última verificação
Mais Informações
Termos relacionados a este estudo
Palavras-chave
Termos MeSH relevantes adicionais
Outros números de identificação do estudo
- 336-13-EP
Plano para dados de participantes individuais (IPD)
Planeja compartilhar dados de participantes individuais (IPD)?
Essas informações foram obtidas diretamente do site clinicaltrials.gov sem nenhuma alteração. Se você tiver alguma solicitação para alterar, remover ou atualizar os detalhes do seu estudo, entre em contato com register@clinicaltrials.gov. Assim que uma alteração for implementada em clinicaltrials.gov, ela também será atualizada automaticamente em nosso site .
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