Clinical trial NCT02351648: A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
Official title: A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Chronic Diseases
Keywords: readmission
care transition
Lead sponsor: Singapore General Hospital
Sponsor class: OTHER
Collaborators: name: Agency for Integrated Care, Singapore
name: Duke-NUS Graduate Medical School
First posted: 2015-01-30
Enrollment: 840
Sex: ALL
Minimum age (years): 21
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: 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: 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)

Eligibility criteria: 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

Primary outcomes:
measure: Readmission rate
timeFrame: 30 days after index discharge
Secondary outcomes:
measure: Readmission rate
timeFrame: up to 180 days after index discharge
measure: Quality of transitional care using a validated care transition measure (CTM-15) tool
timeFrame: 90 days after index discharge
measure: Emergency department attendance rate
timeFrame: Up to 180 days after index discharge
measure: Time to first readmission
timeFrame: Up to 90 days after index discharge
measure: Specialist Outpatient Clinic visits
timeFrame: Up to 180 days after index discharge
Other outcomes:
Locations:
city: Singapore
country: Singapore
facility: Singapore General Hospital
Study officials:
affiliation: Singapore General Hospital
name: Kheng Hock Lee, MBBS
role: PRINCIPAL_INVESTIGATOR
References:
citation: Coleman EA, Smith JD, Frank JC, Eilertsen TB, Thiare JN, Kramer AM. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02. doi: 10.5334/ijic.60. Epub 2002 Jun 1.
citation: Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003 Feb 4;138(3):161-7. doi: 10.7326/0003-4819-138-3-200302040-00007.
citation: Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD004510. doi: 10.1002/14651858.CD004510.pub3.