A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

Study Overview
=================
Brief Summary
-----------------
The investigators conducted an open randomized control study of patients who received the transitional care program versus patients who received usual care at the Singapore General Hospital from Aug 2011 to Sept 2012.

Detailed Description
-----------------
The investigators conducted an open randomized control study of patients who received the transitional care program versus patients who received usual care at the Singapore General Hospital from Aug 2011 to Sept 2012.

Official Title
-----------------
A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

Conditions
-----------------
Chronic Diseases

Intervention / Treatment
-----------------
* Other: Intervention


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Patients with 2 or more unscheduled admission in the last 90 days to selected medical departments LACE score of ≥10. Exclusion Criteria: Non-residents No telephone contact or a resident address Residing in long term care facilities.

Ages Eligible for Study
-----------------
Minimum Age: 21 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
Accepts Healthy Volunteers

Study Plan
=================
How is the study designed?
-----------------

Design Details

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


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control<br>Patients in the control group received usual care by the hospital. There was no contact between the patients in the control group and the study team throughout the 3 months interval. A scheduled telephone call was made at the end of 3 months when they were invited to participate in a telephone survey. | |
| Active Comparator: Intervention<br>Intervention | Other: Intervention<br>* A multidisciplinary team delivered the transitional care program. Our transitional care program focused on four key areas: Post discharge surveillance of the patient to ensure adherence to care plans. Coordination of follow-up visits with specialist care providers. Patent education and care giver training. Activation of community and social services. Upon recruitment, the patients were interviewed and assessed by the team nurse prior to their discharge. Intervention starts upon discharge from the hospital. The duration of the intervention program was 3 months. A follow-up by telephone was made within 72 hours after discharge to assess patient's condition and adherence to treatment plan. Home visits were made within 2 weeks after discharge.<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Rate of readmission | Any hospital admission after randomisation | 30 days | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
readmission, chronic diseases