A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Study Overview
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Brief Summary
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To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

Detailed Description
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Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending Primary Aim: To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Secondary Aim: To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)

Official Title
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A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Conditions
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Chronic Diseases

Intervention / Treatment
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* Other: a transitional care model
* Other: Control


Participation Criteria
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Eligibility Criteria
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Inclusion criteria -More than 1 admission in the last 90 days Exclusion Criteria Subject is a non-resident Subject has no local home address Subject is from a long-term care facility during index admission Subject is unable to participate in telephone surveillance Subject is discharged before takeover Subject has impaired decision making capacity without surrogate decision maker Subject is pending or currently in critical care unit Subject or caregiver is mentally unstable Subject is haemodynamically unstable Subject requires acute inpatient respiratory support Subject requires acute inpatient dialysis support Subject pending surgical intervention Subject pending transfer to other specialist discipline Primary team consultant declined to participate in this research

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Intervention'<br>Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients | Other: a transitional care model<br>* Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients<br>|
| Active Comparator: Control'<br>Patients receive usual standard of care from the internal medicine team | Other: Control<br>* Patients receive usual standard of care from the internal medicine team<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Readmission rate | A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients | 30 days after index discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Readmission rate | Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge | up to 180 days after index discharge | 
| Quality of transitional care using a validated care transition measure (CTM-15) tool | Care transition measure survey of subjects | 90 days after index discharge | 
| Emergency department attendance rate | Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge | Up to 180 days after index discharge | 
| Time to first readmission | Censored time to readmission for both intervention and control group | Up to 90 days after index discharge | 
| Specialist Outpatient Clinic visits | Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge | Up to 180 days after index discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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care transition, readmission