A Trial of the C-TraC Intervention for Dementia Patients

University of Wisconsin (UW)

Status: Completed

Conditions: Dementia

Treatments: Other: C-TraC Intervention

Study type: Interventional

Funder types: Other; NIH

Identifiers

NCT02388711

2014-1221

SMPH\MEDICINE\GER-AD DEV (Other Identifier)

2P50AG033514-06 (U.S. NIH Grant/Contract)

A534255 (Other Identifier)

Protocol Version 8/21/2018 (Other Identifier)

Details and patient eligibility

About

The goal of the project is to conduct a prospective, randomized-controlled clinical trial to determine the extent to which the Coordinated-Transitional Care (C-TraC) program impacts transitional care quality, patient cognition/function, caregiver stress and 30-day rehospitalizations in patients with documented diagnoses of dementia discharged from the hospital to the community.

Full description

Patients with dementia often experience poor quality transitions from the hospital to the community. In response, the investigators developed and piloted the Coordinated-Transitional Care (C-TraC) program--a low-cost, telephone-based intervention designed to improve care coordination and outcomes in hospitalized patients with dementia or other high-risk conditions discharged to community settings.

A single-blind, prospective, randomized-controlled trial will be used with participants being randomly assigned to receive usual (i.e. standard) care, or usual care plus the C-TraC intervention. Outcomes will be assessed via scheduled phone-calls at 14, 30, and 90 days post-hospitalization. A 45-day phone call will also be conducted to complete a brief satisfaction survey with the caregiver about their post-hospital experience.

Enrollment: 584 patients

Sex: All

Ages: 65+ years old

Volunteers: No Healthy Volunteers

Inclusion and exclusion criteria

Patient Inclusion Criteria:

• English-speaking
• Have a working telephone
• Hospitalized on medical inpatient wards at UWHC
• A documented pre-hospitalization diagnosis of dementia.
• Alzheimer's Disease Cooperative Study - Clinical Dementia Rating (ADCS-CDR) score of > 0
• Have a family member/informal caregiver who has regular contact with them in the community setting

Caregiver Inclusion Criteria:

• English-speaking
• Have a working telephone
• Have contact with patient a minimum of once per week

Patient Exclusion Criteria:

• Discharged to institutional settings
• No identified caregiver
• Discharged to hospice
• Followed by complex case management or any form of intensive case management (e.g. transplant, congestive heart failure, dialysis)
• Score moderate-high on modified ASSIST tool for alcohol

Trial design

Primary purpose: Supportive Care

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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584 participants in 2 patient groups

Usual Care with C-TraC Intervention

Experimental group

Description:

Patients/caregivers randomized to this group will receive all routine hospital discharge education/materials (same as usual care group), but will also be enrolled in the C-TraC Program. C-TraC is a low-resource, telephone-based, protocol-driven program designed to reduce 30-day rehospitalizations and to improve care transitions during the early post-hospital period.

Treatment:

Other: C-TraC Intervention

Usual Care

No Intervention group

Description:

Usual care group patients will receive all routine University of Wisconsin Hospital and Clinics (UWHC) discharge education/materials. This includes pharmacy-led medication teaching, physician discussions and routine nursing education. No post hospital education/contact is performed by these providers. Caregivers are sometimes, but not always, involved. Patients may receive home health services, depending on their physician's discharge plan.