Improving Hospital-to-Home Care Transitions for High-risk Younger Adult Patients
Condition: Patient Discharge
Study type: Interventional

Summary: 
      Improving hospital-to-home care transitions can produce improvements in patient safety and
      health care outcomes, while decreasing medical costs. Most transitions research has examined
      strategies for older patients. This project, however, focuses on younger, high-risk patients
      within a safety net system. The proposed intervention is based on research that patient
      activation, as measured by the Patient Activation Measure (PAM), is correlated with risk for
      hospital readmission. The intervention seeks to increase PAM scores by employing a Transition
      Coach to coach patients, prior to and for 30-days after discharge, to (1) improve
      self-management skills through goal setting and goal attainment; (2) to enhance patient
      capacity to engage in trusting relationships with the Primary Care Provider (PCP), other
      medical specialists, family members of friends, and the Transition Coach; and (3) to improve
      ability to navigate the medical system.

      The investigators will conduct a randomized trial to determine; (a) if PAM scores can be
      increased in the 30-day after hospital discharge; (b) if increased PAM scores, in this
      setting, are correlated with changes in healthcare utilization patterns; and (c) if the
      intervention presents a viable strategy to change healthcare utilization patterns and reduce
      rehospitalizations.
    

Detailed description: 
      Patient Activation is defined as the "knowledge, skills, confidence, and inclination to
      assume responsibility for managing one's health and healthcare needs." The 10-item version of
      the Patient Activation Measure (PAM) has been demonstrated to be a valid tool for measuring
      patient activation in a range of patient populations. Evidence demonstrates that PAM scores
      are correlated with heath care outcomes and that targeted interventions can modify PAM scores
      and improve outcomes.

      Highly activated patients, based on their PAM scores, are less likely to experience 30-day
      readmissions, while those with lower levels of activation have higher rates of
      rehospitalization. The investigators propose an intervention to support younger adult
      patients transitioning from hospital to home to assume increased self-care responsibility.
      While hospitalization tends to promote the passive receipt of care, the intervention supports
      patients to take on a more active role. A Transition Coach will assist patients to prepare
      for discharge to enhance their ability to self-manage medications, follow-up appointments,
      symptoms, community services, and personal goals. The investigators hypothesize that
      intensified pre-discharge involvement in improving self-management skills for younger
      high-risk patients can; (a) improve PAM scores, (b) improve post-discharge engagement with
      medical, psychiatric and community-based care; and (c) present a strategy for changing
      healthcare utilization patterns that maximize outpatient care and reducing inpatient care,
      including hospital readmissions.

      Patient Selection:

      Cambridge Health Alliance (CHA) is a public safety-net system serving an ethnically diverse,
      underserved patient population of whom 30% are non-English speaking and 87% are publically
      insured. Our target group is high risk hospitalized medical patients age 60 and younger, who
      are discharged to home and receive primary care within the CHA network. Patients are
      considered high risk if they have had a previous inpatient admission or multiple Emergency
      Department (ED) visits within the past year, which serves as a proxy for complicated medical
      or psychosocial issues. Patients will be selected from the Medicine or Surgical Services at
      Cambridge Hospital.

      Study Protocol:

      The study protocol is described below.

        1. The investigators anticipate enrolling 100 intervention patients and 100 control
           patients over 9 months.

        2. A research assistant (RA) administers the Patient Activation Measure to intervention
           patients and control patients, immediately after randomization.

      2- The intervention occurs with selected patients. 3- RA administers a post-discharge PAM to
      all patients 31 days after discharge.

      Statistical Analysis:

      Data will be extracted from the Electronic Medical Record (EMR) on all study patients.
      Baseline data will include age, sex, insurance status, Charlson comorbidity score, mental
      health and substance abuse disorders, marital status, homelessness, and address changes,
      admissions and ED visits in the past year.

      Modest sample sizes may limit our ability to observe statistically significant effects. The
      PAM score is calculated with a scale of 0 to 100 (highest activation), with scores typically
      converted to a four-category categorical scale. Based on previous work in safety net
      settings,18 the investigators expect about 45% of control patients to have a PAM score of
      Level 4 (highly activated). With 100 intervention and 100 control patients, assuming
      two-sided alpha=0.05, the investigators would have 89% power to detect a 20% increase in the
      percentage of highly activated patients in the intervention group, and 65% power to detect a
      15% increase. A key outcome is having an outpatient visit within 7 days of discharge. Based
      on our current work, only 15% of control patients in this group complete a 7-day visit. The
      investigators would have 81% power to detect an increase of 15% in the visit rate in the
      intervention group, and 50% power to detect a 10% increase.

      Study Hypothesis:

      The investigators expect to observe positive gains in PAM scores following the intervention,
      increases in 7-day outpatient follow-up rates and reductions in 30-day readmissions.
    

Intervention name(s): Transition Coach (TC); Control
Intervention type(s): Behavioral; Behavioral
Intervention description(s): TC reviews patient's medical record to understand current admission and the medical/psycho-social history. TC makes introductory hospital visit(s) with patient to establish rapport and to define post-discharge needs.
Starting in-house and continuing after discharge, TC helps patient set transition goals to maximize healthcare outcomes. Post-discharge, TC offers a voluntary face-to-face visit with patient along with weekly outreach calls, which are designed to assist patient with goal setting and attainment, medical system navigation; medication management; medical follow-up; transportation; use of community resources; and self-care.
Intervention lasts 30 days post-discharge; afterwards TC seeks to handoff to an outpatient care team member, to ensure continuity of care.; Receives usual hospital-based care, discharge preparation, transitional care and outpatient care.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Health Services Research