Care Transitions Innovation (C-TraIn)

Study Overview
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Brief Summary
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The purpose of this protocol is to evaluate the Care Transitons Innovation, a quality improvement project being implemented at OHSU to improve the transition from hospital to home for uninsured and Medicaid patients admitted to general medicine and cardiology wards at OHSU. The evaluation includes a baseline in-person survey and a 30 day post-discharge phone follow-up survey. Prior to C-TraIn, the local healthcare delivery model lacked an effective way to assure timely, safe, and effective follow-up care for uninsured and underinsured hospitalized patients. Most uninsured patients have no source for primary care, and many have limited social support, complex medical problems, and are prescribed many medications. Patients are frequently discharged without any coordinated plan for follow up. Based on a needs assessment performed in 2009 (OHSU eIRB 5514) investigators developed a quality improvement program that will include three major components: 1) a care transitions RN advocate who will see patients in the hospital and after discharge, 2) a pharmacy consultation and 30 days of medications post-discharge, 3) linkages with primary care medical homes, including payment for primary care for uninsured patients who lack a usual source of care, and 4) monthly meetings that serve as a platform for continuous quality improvement. In order to measure the success of our program, investigators will track patient utilization, sociodemographic factors, and patient factors including satisfaction, activation, and self-reported health status. To be included patients must be uninsured, have Oregon Medicaid, or be low income (200% or less of federal poverty level) Medicare recipients, and live within Multnomah, Washington and Clackamas Counties in Oregon.

Official Title
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Care Transitions Innovation (C-TraIn): Study of a Multi-component Transitional Care Intervention for Uninsured and Low-income Publicly Insured Adults

Conditions
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Hospitalization

Intervention / Treatment
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* Other: Care Transitions Innovation (C-TraIn)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: hospitalized on one of seven inpatient treatment teams uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and ≤200% poverty level) reside in one of three metro-area counties (Multnomah, Washington, Clackamas) Exclusion Criteria: not community dwelling (ie not from a long-term care facility or with plans to discharge to skilled nursing facility) no access to a working telephone (participants could list a friend or shelter phone) non-English speakding HIV positive (HIV+ patients were eligible for overlapping transitional care resources) disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits plans to enter hospice.

Ages Eligible for Study
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Minimum Age: 18 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
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Usual Care<br>Usual care consists of 1) a routine nurse intake 2) medication reconciliation performed by treating physicians. Given resource constraints (routine medication reconciliation did not include corroborating medication histories with outpatient pharmacies, routine use of pill cards or pill boxes, or review of Medicaid formularies) Uninsured patients were financially responsible for most medications at discharge. 3) Discharge patient education was performed by inpatient nurses and treating physicians at the time of discharge. 4) Patients without a usual source of primary care were often given a list of the fourteen area safety-net clinics, which have limited capacity for uncompensated care. | |
| Experimental: C-TraIn<br>Care Transitions Innovation (C-TraIn) was delivered in addition to usual care, and includes (1) transitional nurse coaching and education, including post-discharge phone calls and home visits for highest risk patients; (2) pharmacy care that includes patient education, medication reconciliation, guidance to inpatient providers to encourage low-cost medications, and provision of 30 days of medications after discharge for those without prescription drug coverage; (3) post-hospital primary care linkages; (4) and explicit efforts at system integration through monthly quality improvement meetings. | Other: Care Transitions Innovation (C-TraIn)<br>* Multi-component transitional care intervention including transitional nursing care, pharmacy care, and medical home linkages<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 30-day hospital readmissions |  | 30-days | 
| Emergency Department use |  | 30-days post-discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Care Transitions Measure (CTM-3) | The 3 item care transitions measure (CTM-3) is a validated measure that assesses the quality of the care transition. It asks patients to rate agreement with the following: The hospital staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left the hospital. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. When I left the hospital, I clearly understood the purpose for taking each of my medications. It is being considered by NQF for public reporting. More Background can be found at: http://www.caretransitions.org/documents/CTM_FAQs.pdf | Patient report at 30-days post hospital discharge | 
| all cause mortality |  | 30-days post-discharge | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Patient Readmission, Continuity of Patient Care