Community Health Worker Intervention to Improve Post-Hospital Outcomes (CHW)

University of Illinois

Status: Terminated

Conditions: Chronic Disease (Physical); Mental Disorder

Treatments: Behavioral: Healthy at Home; Other: Services as Usual

Study type: Interventional

Funder types: Other; Other U.S. Federal agency

Identifiers

NCT04028609

90RT5038a (Other Grant/Funding Number)

2018-0715

Details and patient eligibility

About

This study tests an intervention designed to avoid 30-day readmissions following a medical hospitalization by patients who have co-occurring mental illness. The Intervention is delivered by community health workers in the inpatient setting and 30 days following hospital discharge to the community.

Full description

This study will test the efficacy of a brief intervention delivered to adults with co-occurring medical and mental health conditions by community health workers designed to avoid 30-day readmissions following medical hospitalization. Adult inpatients of a university hospital will be randomly assigned to the intervention plus services as usual versus services as usual alone, and assessed at baseline and 30 days following discharge. Chi square will be used to assess the primary outcome of admission within 30 days of discharge and changes in patient activation, mental health symptoms, medication adherence, and perceived competence for health maintenance. Also examined will be study condition differences in post-discharge inpatient service utilization and cost.

Enrollment: 55 patients

Sex: All

Ages: 21 to 60 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• receiving inpatient treatment for chronic medical condition
• evidence of a mental health diagnosis
• age 21- 60 years
• expected to return to community residence
• residing within a 30-mile radius of the hospital
• expected to remain in hospital for 2 or more days
• able to provide informed consent

Exclusion criteria

• terminally ill
• unable to communicate in English
• expected to be discharged to skilled facility or nursing home
• participating in another transitional care intervention
• hospitalized for behavioral health disorder

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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55 participants in 2 patient groups

Intervention

Experimental group

Description:

Subjects receive an intervention with 4 components: development of a personal health plan; review and support for medication adherence; connection with primary care provider within 30 days; and education about clinical indicators that call for immediate intervention.

Treatment:

Behavioral: Healthy at Home

Services as Usual

Active Comparator group

Description:

Subjects receive medical services as usual.

Treatment:

Other: Services as Usual