Effectiveness of Nurse-based Care Coordination on Readmissions Among Primary Care Patients: a Stepped Wedge Cluster Randomized Trial
Status
Completed
Conditions
Patient Activation
Treatments
Other: Remote Patient Monitoring
Other: Adult Medical Care Coordination
Details and patient eligibility
About
This trial will evaluate the effectiveness of nurse-based care coordination and nurse-based remote patient monitoring on hospital readmissions among primary care patients.
Enrollment
1,947 patients
Sex
All
Ages
18+ years old
Volunteers
No Healthy Volunteers
Inclusion criteria
- Discharged from the hospital in the past 7 days
- LACE+ score of 59 or greater and at least two chronic conditions
- Index hospitalization with discharge directly to community dwelling home (home, assisted living)
- English speaking
- Normal cognitive function - mild dementia or mild cognitive impairment is allowed if a caregiver is able to work with the care coordinator and patient during program enrollment
- Mayo Clinic or Mayo Clinic Health System provider managing the patient's care (e.g. primary care); patient is assigned to the panel of a Mayo Clinic Medical Doctor/Nurse Practitioner/Physician Assistant
- Access to and ability to communicate via telephone (either patient or caregiver)
Exclusion criteria
- Psychiatric hospital admission
- Patients with a serious and persistent mental health disorder or severe treatment interfering behavior that require a higher level of service than is available at the patient's clinic
- Untreated active substance or alcohol abuse
- Dementia or moderate to severe cognitive impairment
- Discharged to one of the following: rehabilitation unit, skilled nursing facility, assisted living memory unit, group home
- Pregnancy
- Active treatment for cancer
- Receiving dialysis or transplant services
- Life expectancy < 6 months or enrolled in hospice or palliative care programs
- Patient is unwilling to sign a Release of Information (ROI); ROI allows those providing care, internal and external, to be actively involved in the patient's care coordination
- Patients with active tuberculosis (TB)
- Violent patient flag noted in Epic (for adult medical care coordination)
- Patient declines home visit (for adult medical care coordination)
- Patient is already enrolled in remote patient monitoring or the care transitions program
Trial design
Primary purpose
Health Services Research
Allocation
Randomized
Interventional model
Sequential Assignment
Masking
None (Open label)
1,947 participants in 3 patient groups
Adult Medical Care Coordination
Active Comparator group
Description:
This group will receive adult medical care coordination following discharge from a recent hospitalization.
Treatment:
Other: Adult Medical Care Coordination
Remote Patient Monitoring
Active Comparator group
Description:
This group will receive remote patient monitoring following discharge from a recent hospitalization.
Treatment:
Other: Remote Patient Monitoring
Usual Care
No Intervention group
Description:
The usual care group will not receive additional supportive care following discharge from a recent hospitalization beyond what is typically offered through their primary care team.
Trial contacts and locations
1
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Data sourced from clinicaltrials.gov
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