Please select the arm or intervention descriptions that belong 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: Arm Label: Diabetes-Specific CBT (DS-CBT); Type: EXPERIMENTAL; Interventions: Behavioral: Diabetes-Specific CBT (DS-CBT) | Arm Label: Standard Diabetes Education; Type: ACTIVE_COMPARATOR; Interventions: Behavioral: Standard Diabetes Education | Intervention Type: BEHAVIORAL; Name: Diabetes-Specific CBT (DS-CBT); Assigned to Arm(s): Diabetes-Specific CBT (DS-CBT) | Intervention Type: BEHAVIORAL; Name: Standard Diabetes Education; Assigned to Arm(s): Standard Diabetes Education
B: Arm Label: Intervention; Type: EXPERIMENTAL; Interventions: Behavioral: Intensive diabetes self-management education | Arm Label: Control Group; Type: ACTIVE_COMPARATOR; Interventions: Behavioral: Enhanced standard diabetes education | Intervention Type: BEHAVIORAL; Name: Intensive diabetes self-management education; Assigned to Arm(s): Intervention | Intervention Type: BEHAVIORAL; Name: Enhanced standard diabetes education; Assigned to Arm(s): Control Group
C: Arm Label: Patient Navigator; Type: EXPERIMENTAL; Interventions: Other: Patient Navigator, Other: Usual care | Arm Label: Usual Care; Type: NO_INTERVENTION; Interventions: N/A | Intervention Type: OTHER; Name: Patient Navigator; Assigned to Arm(s): Patient Navigator | Intervention Type: OTHER; Name: Usual care; Assigned to Arm(s): Patient Navigator
D: Arm Label: CHAP-EMS/CP@clinic Program Intervention; Type: EXPERIMENTAL; Interventions: Behavioral: CHAP-EMS/CP@clinic | Arm Label: Control; Type: NO_INTERVENTION; Interventions: N/A | Intervention Type: BEHAVIORAL; Name: CHAP-EMS/CP@clinic; Assigned to Arm(s): CHAP-EMS/CP@clinic Program Intervention

Answer: C