Effectiveness of Transitional Care Services
Condition: Post-cardiac Surgery
Study type: Interventional

Summary: 
      The National University Hospital System has designed and is piloting an improved
      post-discharge care programme called CareHub for patients undergoing cardiac surgery. CareHub
      is a post-discharge care programme that is designed to streamline and better coordinate
      current programmes for patients at high risk of readmission.

      To assess the clinical and cost-effectiveness of CareHub, our team will randomly assign
      patients to a usual care setting or CareHub setting, and measure clinical outcomes, patient
      satisfaction, readmissions, and length of stay through 6 months post-discharge in both
      groups.Patients enrolled in both groups will receive post-discharge care for six months after
      discharge. CareHub patients will receive a single point of contact for access to usual care
      services. Recruitment for this pilot will be from 20 April 2016 - approximately late October
      2016, and the CareHub team will provide 6 months of post-discharge support. The entire pilot
      will thus run from 20 April 2016 - April / May 2017, with data collection extending 6 months
      after the last patient is enrolled.
    

Detailed description: 
      Today, the National University Hospital System has a variety of transitional / post-discharge
      care programmes, and patients may be enrolled in more than one. Each of these programmes is
      run by a different hospital team, so a patient may have to liaise with many parties for their
      post-discharge care.

      The National University Hospital System has designed and is piloting an improved
      post-discharge care programme called CareHub for patients undergoing cardiac surgery.
      Recruitment for this pilot will be from 20 April 2016 - approximately late October 2016, and
      the CareHub team will provide 6 months of post-discharge support. The entire pilot will thus
      run from 20 April 2016 - April / May 2017.

      CareHub is a post-discharge care programme that is designed to streamline and better
      coordinate current programmes for patients at high risk of readmission. Patients enrolled in
      CareHub and usual care will receive post-discharge care for six months after discharge.
      However, patients in CareHub will experience:

      (i) Provision of a single point of contact for all the patient's needs, to help patients and
      their families navigate the healthcare system as well as various programmes available in the
      hospital and community. Care Coordinator identifies patients and starts working with care
      team during the inpatient phase, and follows patient through to the post-discharge phase.

      (ii) More structured and regular telephone support and checks, to help ease the
      hospital-to-home transition, as well as to provide more opportunity to verify that patients
      are adhering to their recommended treatment (which may include e.g. checking that patients
      have made use of the daycare services CareHub recommended).

      (iii) A call center which will operate during office hours, where tele-consult will be
      available from and nurses/care coordinators.

      (iv) A consolidated multi-disciplinary discharge plan, based on the input of all healthcare
      workers caring for the patient. These include the CareHub coordinator, ward doctor and nurse,
      heart failure care manager, and allied health professionals, as required.

      (v) Early identification and preparation for post-discharge care. Healthcare workers listed
      in (iv) will participate in a daily in-patient multi-disciplinary ward huddle, to discuss the
      patient's condition and start early preparation for post-discharge care.

      To assess the clinical and cost-effectiveness of CareHub, our team will randomly assign
      patients to a usual care setting or CareHub setting, and measure clinical outcomes, patient
      satisfaction, readmissions, and length of stay through 6 months post-discharge in both
      groups.
    

Intervention name(s): Usual Care; CareHub
Intervention type(s): Behavioral; Behavioral
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Patients are randomly assigned to one of two groups. Group 1 is usual care, in which patients are followed up after surgery by the ambulatory clinic assigned to their case. Patients in usual care have access to occupational and physical therapy, and medical social work, if they choose to use them. Group 2 is CareHub, in which patients are followed up by a dedicated care coordinator who proactively calls patients at home and schedules their clinic appointments, and consults with therapists and medical social workers.
Masking: None (Open Label)
Primary purpose: Health Services Research