A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Singapore Health Services (SingHealth)

Status: Completed

Conditions: Chronic Diseases

Treatments: Other: Control; Other: a transitional care model

Study type: Interventional

Funder types: Other

Identifiers

NCT02351648

2012/848/E

Details and patient eligibility

About

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

Full 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)

Enrollment: 840 patients

Sex: All

Ages: 21+ years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion 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

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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840 participants in 2 patient groups

Intervention'

Experimental group

Description:

Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients

Treatment:

Other: a transitional care model

Control'

Active Comparator group

Description:

Patients receive usual standard of care from the internal medicine team

Treatment:

Other: Control