Clinical trial NCT02684188: Rural Options At Discharge Model of Active Planning
Official title: Rural Options At Discharge Model of Active Planning
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: All Causes Hospital Admissions
Lead sponsor: University of Montana
Sponsor class: OTHER
Collaborators: name: Providence St. Patrick Hospital, Missoula Montana
First posted: 2016-02-17
Enrollment: 127
Sex: ALL
Minimum age (years): 18
Maximum age (years): 75
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NON_RANDOMIZED
Intervention model: PARALLEL
Intervention model description: Patients were recruited from those admitted from one of four rural counties. In the initial phase, all patients enrolled from any county were assigned to a baseline condition. After enrollment stabilized, patients from one county were enrolled in the intervention while patients from the other three counties remained in baseline. Subsequently the intervention was introduced to the other counties sequentially while others remained in baseline. A return to baseline conditions followed a period after the intervention had been introduced in all counties.
Primary purpose: SUPPORTIVE_CARE

Brief summary: Residents of rural and frontier counties experience significant disparities in health care access and outcomes when compared to their urban counterparts. The organization of health care delivery contributes significantly to these disparities. For rural residents with multiple chronic conditions, transitioning along the continuum of care, between systems of treatment and support, and between dispersed locations present significant challenges. One critical challenge involves hospitalization for treatment because it requires travel to locations at a significant distance from home and disrupts personal and family routines. The transition back home is also problematic because discharge planning does not adequately account for limited access to care in rural areas. Indeed, discharge planning has been recently described as a "black hole;" fragmented and uncoordinated, and contributing to poor outcomes and patient dissatisfaction. The specific aim of this research is to ascertain rural patients' actual experience of the discharge planning process and to involve patients and rural providers in designing and testing a contextually appropriate rural options discharge model (ROADMAP) that improves patient outcomes and reduces re-hospitalizations.

Detailed description: Residents of rural counties experience significant disparities in health care access and outcomes when compared to their urban counterparts. These disparities are structural; based in our market-based medical care delivery system. For rural residents with multiple chronic conditions, transitioning along the continuum of care, between systems of treatment and support, and between dispersed locations both expose and produce disparities. The transition home from hospitalization for treatment exposes the current urban bias. Indeed, discharge planning is fragmented and uncoordinated, and contributes to poor the disparities. The specific aims of this research is to ascertain rural patients' actual experience of discharge; then to involve patients and rural providers in using those data to design a contextually appropriate rural options at discharge model of active planning (ROADMAP) that improves patient outcomes and reduces disparities. Objectives include:

1. Ascertain actual patient experience in the rural discharge process.
2. Design the ROADMAP model to fit the emerging health services context.
3. Test the ROADMAP's efficacy in enhancing patient defined outcomes.
4. Design the components for rapid diffusion.

Researchers will work in four counties of the Missoula Hospital Referral Region with a total population of 53,116 living on 12,342 square miles (4.3 persons per square mile). Researchers will recruit patients seeking treatment from St. Patrick Hospital. Patients and patient advocates will serve on an Innovations Design Team (IDT) to create the ROADMAP. Researchers will first interview patients (n = 40) who have been discharged to one of the rural counties. Researchers will compare their experiences to guidelines. Next, they will conduct a Design Survey (n=600) to verify goals important to patients. The IDT will use these findings to develop design requirements for ROADMAP. Finally, we will use a quasi-experimental research design to compare the patient designed rural ROADMAP to standard practice. The primary outcome measures are measures that reflect the patient's values for health-related quality of life and functional status, as well as hospital re-admissions. An independent statistician will use Hierarchical Linear Modeling to examine the complex relationships. This approach accounts for patients nested in four counties and the correlated errors inherent in within subject analysis. Health care reform sets the occasion for rapid diffusion of ROADMAP. This can provide an incremental reduction in rural disparities. Incorporating patient and provider input increases the likelihood it will fit within the emerging reimbursement model. Researchers expect that ROADMAP will reduce re-hospitalizations by as much as 30%, and improve patient recovery and return to participation in daily life.

Eligibility criteria: Inclusion Criteria:

* Between 18 and 75 years of age
* Admitted to St. Patrick regional referral hospital for treatment
* Discharged home to one of four rural counties in Montana

Exclusion Criteria:

* Primary diagnosis involves psychiatric condition or substance abuse
* Inmates of state prison
* Admitted under ongoing criminal investigation.

Primary outcomes:
measure: Hospital Re-admissions Analyzed by Poisson Regression
timeFrame: 3, 7 ,14, 21, 30, 60, and 90 days after discharge
measure: Hospital Re-admissions Analyzed by Logistic Regression
timeFrame: 3, 7 ,14, 21, 30, 60, and 90 days after discharge
measure: Emergency Department (ED) Visits Analyzed by Poisson Regression
timeFrame: 3, 7, 14, 21,30, 60, and 90 days after discharge
measure: Emergency Department (D) Visits Analyzed by Logistic Regression
timeFrame: 3, 7, 14, 21,30, 60, and 90 days after discharge
measure: Primary Care Provider (PCP) Visits Analyzed by Poisson Regression
timeFrame: 3, 7, 14, 21, 30, 60, and 90 days after discharge
measure: Primary Care Provider (PCP) Visits Analyzed by Logistic Regression
timeFrame: 3, 7, 14, 21, 30, 60, and 90 days after discharge
Secondary outcomes:
measure: Short Form (SF12) Physical Health Score
timeFrame: 3, 7, 14, 21, 30, 60, and 90 days after discharge
measure: Short Form (SF12) Mental Health Score
timeFrame: 3, 7, 14, 21, 30, 60, and 90 days after discharge
measure: Care Transition Measure (CTM3)
timeFrame: 3 days after discharge
measure: Rural Transition Measure (RTM14)
timeFrame: 7, 14, 21, 30, 60, and 90 days after discharge
Other outcomes:
Locations:
Study officials:
affiliation: University of Montana
name: Tom W Seekins, Ph.D.
role: PRINCIPAL_INVESTIGATOR
References: