Clinical trial NCT01906645: Care Transitions Innovation (C-TraIn)
Official title: Care Transitions Innovation (C-TraIn): Study of a Multi-component Transitional Care Intervention for Uninsured and Low-income Publicly Insured Adults
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Hospitalization
Keywords: Patient Readmission
Continuity of Patient Care
Lead sponsor: Oregon Health and Science University
Sponsor class: OTHER
First posted: 2013-07-24
Enrollment: 382
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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.


Eligibility criteria: 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.

Primary outcomes:
measure: 30-day hospital readmissions
timeFrame: 30-days
measure: Emergency Department use
timeFrame: 30-days post-discharge
Secondary outcomes:
measure: Care Transitions Measure (CTM-3)
timeFrame: Patient report at 30-days post hospital discharge
measure: all cause mortality
timeFrame: 30-days post-discharge
Other outcomes:
measure: Patient Activation Measure
timeFrame: 30-days post-discharge
Locations:
city: Portland
country: United States
facility: Oregon Health & Science University
state: Oregon
Study officials:
References:
citation: Englander H, Kansagara D. Planning and designing the care transitions innovation (C-Train) for uninsured and Medicaid patients. J Hosp Med. 2012 Sep;7(7):524-9. doi: 10.1002/jhm.1926. Epub 2012 Mar 12.
citation: Englander H, Michaels L, Chan B, Kansagara D. The care transitions innovation (C-TraIn) for socioeconomically disadvantaged adults: results of a cluster randomized controlled trial. J Gen Intern Med. 2014 Nov;29(11):1460-7. doi: 10.1007/s11606-014-2903-0. Epub 2014 Jun 10.