Transition From Hospital to Home Post Cardiac Condition
Pilot Intervention to Improve the Transition From Hospital to Home
The study had three parts:
Part 1: Patients (or their home caretakers) who live outside of Denver and receive their primary care at a location other than the Denver VAMC were interviewed after their discharge. The interview covered the patient's perspective about the transition of their medical care from the Denver VA to their primary care facility.
Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA were interviewed regarding their opinions of transition process from the Denver VA back to the primary care VA facilities.
Part 3: The data from the above interviews were used to develop an intervention to improve the transition process from the Denver VA back to the primary care VA facilities.
研究概览
详细说明
Aim 1 was to describe barriers and facilitators of the transition process from hospital to home through qualitative interviews among patients discharged from Denver VA Medical Center (tertiary facility) after being transferred from a primary care VA.
Aim 2 was to describe barriers and facilitators of the transition process through qualitative interviews among providers at primary care VA facilities who take care of patients discharged from the Denver VA Medical Center for a cardiac condition.
Aim 3 was to pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention. This pilot was informed by the interviews from Aims 1 and 2 and best practices from the literature. Finally, as part of Aim 3, the primary care providers who saw the patients who completed the pilot were contacted to ask for their input and feedback regarding the pilot project.
Description of Enrolled Population: Study Design and Research Methods This was a mixed methods study where both qualitative and quantitative methods were employed. Through a series of qualitative interviews (n=26), potential barriers and facilitators of the current discharge process were assessed in this hub and spoke model of cardiac care. Informed by these interviews, the transitions of care intervention refined elements from prior studies that have improved this transition process. Finally, a pilot test of this intervention was implemented to assess the effectiveness of the intervention to improve important processes of care during this transition period among patients (n=8) discharged from Denver VAMC after transfer from a primary care VA facility.
研究类型
注册 (实际的)
阶段
- 不适用
联系人和位置
学习地点
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Colorado
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Denver、Colorado、美国、80220
- VA Eastern Colorado Health Care System, Denver, CO
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参与标准
资格标准
适合学习的年龄
接受健康志愿者
有资格学习的性别
描述
Inclusion Criteria:
Aims 1 and 3:
- Patients transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider, were eligible.
Aim 2:
- Providers from VA primary care facilities, (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) who took care of patients discharged from the Denver VAMC for cardiology care, were eligible for the qualitative interviews.
Exclusion Criteria:
Aims 1 and 3:
Exclusion criteria included:
- Planned discharge to nursing home or skilled nursing facility;
- Irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol;
- Lack of telephone/ cell phone; and
- VA is not their primary source of care or their PCP is not in the VA system.
Aim 2: There were exclusion criteria.
学习计划
研究是如何设计的？
设计细节
- 主要用途：卫生服务研究
- 分配：非随机化
- 介入模型：并行分配
- 屏蔽：无（打开标签）
武器和干预
参与者组/臂 |
干预/治疗 |
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无干预：Discharge Patient
Eight patients who were being discharged from Denver VA Medical Center for cardiac care to their primary care providers were recruited at the time of discharge and completed an interview two weeks following their discharge.
Patients were asked to describe their transition to home and identify barriers and facilitators of this process, their understanding of their medical condition, new medications prescribed, timeliness of follow-up visit with their PCP and knowledge of signs/symptoms in which they should seek medical attention.
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无干预：Providers
Three providers who refer patients to the Denver VA Medical Center for cardiac care were interviewed to identify barriers and facilitators from their perspective of following-up with patients after their hospitalization at Denver VAMC.
Additionally, the same information was asked of providers who participated in two focus groups in the Grand Junction VA.
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实验性的：Intervention
Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention
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Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention
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研究衡量的是什么？
主要结果指标
结果测量 |
措施说明 |
大体时间 |
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See Primary Outcome Description Below
大体时间：Within 2 weeks of discharge
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Follow up appointment within 2 weeks of discharge back to their primary care providers at a primary care facility from a tertiary referral center.
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Within 2 weeks of discharge
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合作者和调查者
调查人员
- 首席研究员：Michael Ho, MD PhD、VA Eastern Colorado Health Care System, Denver, CO
出版物和有用的链接
研究记录日期
研究主要日期
学习开始
初级完成 (实际的)
研究完成 (实际的)
研究注册日期
首次提交
首先提交符合 QC 标准的
首次发布 (估计)
研究记录更新
最后更新发布 (估计)
上次提交的符合 QC 标准的更新
最后验证
更多信息
此信息直接从 clinicaltrials.gov 网站检索，没有任何更改。如果您有任何更改、删除或更新研究详细信息的请求，请联系 register@clinicaltrials.gov. clinicaltrials.gov 上实施更改，我们的网站上也会自动更新.
Cardiac Condition的临床试验
Intervention的临床试验
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University of Illinois at ChicagoShirley Ryan AbilityLab; Oakland University; Access Living主动，不招人
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University of Wisconsin, MadisonNational Cancer Institute (NCI); Northwestern University主动，不招人