Effectiveness of Transitional Care Services

Study Overview
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Brief Summary
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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
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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.

Official Title
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Can Refinements to Effective Transitional Care Services Improve Outcomes? Results From a Pragmatic, Randomized Controlled Trial.

Conditions
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Post-cardiac Surgery

Intervention / Treatment
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* Behavioral: Usual Care
* Behavioral: CareHub


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: All patients admitted to the cardiac inpatient service post-cardiac surgery Exclusion Criteria: Patients that do not consent or are unable to consent to be included into CareHub

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 99 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
Interventional 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)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Usual Care<br>Telephone and/or home visits at 1 week, and thereafter, monthly for 6 months, to check on medication compliance and/or medical social problems and/or physical therapy needs and/or health-related financial challenges by the relevant service departments as recommended by the discharging physician. | Behavioral: Usual Care<br> <br> |
| Active Comparator: CareHub<br>Telephone follow-up by a nurse care coordinator acting as single point of contact for medication compliance and/or medical social problems and/or physical therapy needs and/or health-related financial challenges based on automatic enrollment using ACE score cut-off at admission. | Behavioral: CareHub<br> <br> |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post-discharge length of stay | Patient's length of stay for any readmissions following index admission | 6 months | 
| Unplanned readmissions | Whether patients were admitted for a cardiac complaint after index admission | 6 months | 
| Cardiac-related specialist outpatient clinic visits | The number of post-index admission visits to an outpatient clinic for cardiac consults | 6 months | 
| Emergency department visits | The number of emergency department visits post-index admission | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Net cost of service utilization | CareHub cost/patient minus Usual Care cost/patient | 6 months |