Please select the eligibility criteria that correspond to the clinical trial below.
Title: Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population
Brief Summary: Hospital readmissions are common, costly, and potentially preventable. They are also potentially responsive to health system interventions. However, it is uncertain which components of care transition interventions are efficacious, for which populations, and at what cost. This randomized controlled study is part of a larger project that will evaluate a three-tiered quality improvement (QI) intervention intended to reduce hospital readmissions within 30 days post-discharge from an urban safety net hospital that serves a racially and linguistically diverse population (the randomized controlled study evaluates Tier 3). Few studies have evaluated care transition interventions to reduce readmissions among low-income, diverse patient populations, and the accumulated evidence on the effects of these multi-faceted interventions on readmission rates has been inconclusive. This project will take advantage of a unique sequence of three QI innovations to reduce hospital readmissions implemented beginning in 2007 in an integrated safety net health care system. The "discharge-transfer" tiers are as follows: 1) Tier 1 includes a comprehensive, individualized home care plan (HCP) reviewed by the medical service floor nurse with the patient prior to discharge; 2) Tier 2 adds the electronic transmission of the HCP to the patient's primary care medical home where, on the business day following discharge, a Registered Nurse makes an outreach telephone call to the discharged patient to confirm comprehension of the HCP and to address medical questions or needs; 3) Tier 3 further adds a community health worker, the Patient Navigator, to participate in bedside discussions to develop rapport and learn about patients' home situations, weekly outreach calls to assess patients' needs and to facilitate communication between the patient and the primary care team, and reminder calls to patients prior to all medical appointments to eliminate barriers to outpatient follow-up. The Aim of the study being registered is to evaluate the effects of an ongoing randomized natural experiment on readmissions, health care use, adherence to medication instructions, and preparedness for discharge. This natural experiment features random assignment to one of two QI interventions, Tier 2 or Tier 3, and exclusively targets patients at high risk for readmission, those with one or more of the following risk factors for readmission: discharge diagnosis of congestive heart failure or COPD; length of stay \> 3 days; age \> 60; or previous hospitalization within the past six months.

The investigators hypothesize that the Patient Navigator intervention (Tier 3) compared to usual care (Tier 2) will increase the rates of 30-day post-discharge PCP visits; reduce 30-day hospital readmission rates; and reduce the total number of days in hospital in the 180 days following the index admission for high risk patients. The investigators further expect that the PN intervention will improve patient adherence to medication instructions in the HCP and reduce the probability of reported problems with post-discharge care.


Options:
A: Inclusion Criteria:

* Hospitalized at Vanderbilt University Medical Center
* Medicare-eligible
* Discharged from VUMC to a post acute care facility
* Has polypharmacy as defined by \> 5 medications
* Able to self-consent or has a proxy (surrogate)
* Speaks English (due to interview-based assessments)
* Primary home residence within one of 9 surrounding counties (due to home visit during follow-up phase)

Exclusion Criteria:

* Resides in long-term care
* Is currently on hospice or otherwise has a limited life expectancy (\< 6 months).
* Enrolled in a clinical drug trial
* Has Stage IV Cancer Diagnosis
* Incarcerated or homeless
* Unable to self-consent and does not have a surrogate
B: Inclusion Criteria:

* medical patients discharged to home or skilled nursing facility between October 1, 2011 and June 30, 2013
* Cambridge Health Alliance PCP at time of discharge
* at least one of four risk factors for readmission: discharge diagnosis of CHF or COPD; length of stay \>3 days; age \>60; or previous hospitalization within the past 6 months
C: Inclusion Criteria:

* People 70 years of age or older
* Multimorbidity: 3 or more coexistent chronic conditions defined by 3 distinct International Classification of Diseases (ICD-10) codes with an estimated duration of 6 months or more or based on a clinical decision
* Polypharmacy i.e. five or more different regular drugs (defined as authorised medications with registration numbers) for more than 30 days.
* In inpatient: Estimated minimal length of stay within the cluster is sufficient to apply the intervention
* If outpatient: prescribing physician has GP function and has a planned appointment to conduct intervention

Exclusion Criteria:

* Inability to provide informed consent or to obtain informed consent from a proxy for patients with cognitive impairment
* Direct admission to palliative care (\< 24h after admission)
* Has passed or will pass a systematic structured drug review during this hospitalisation or within the last two months
D: Inclusion Criteria:

* Subjects aged under 18 or over 65 years
* Subject hospitalized in the multidisciplinary pediatric service or internal medicine ward, after emergency department visit at Timone hospital (Marseille, France) regardless of the reason for admission
* Subject with or without any comorbidity
* Living in France
* With national publicly-founded health insurance

Inclusion criteria for parents of minor child:

* Major subject and/or holder of parental authority of a hospitalized child, who fulfills the eligibility criteria mentioned above, in the multidisciplinary pediatric ward;
* Whatever the reason for hospitalization of the patient;

Inclusion criteria for the caregivers of patients older than 65 years:

* Major subject, designated by the patient or designating himself as the person most involved in the daily life of the patient;
* Whatever the reason for hospitalization of the patient;
* Whatever relationship or proximity to the study patient (family member, friend, neighbor);

Exclusion Criteria:

* Patients whose care requires regular re-hospitalization / programmed less than 30 days after discharge of initial hospitalization
* Vulnerable persons according to French law (pregnant women, adults under guardianship, persons deprived of liberty)

Answer: B