Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward (PROUST)

Civil Hospices of Lyon

Status: Completed

Conditions: Geriatrics

Treatments: Other: standard care program; Other: Transitional care program.

Study type: Interventional

Funder types: Other

Identifiers

NCT02421133

2014.874

Details and patient eligibility

About

In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.

Full description

The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,

Enrollment: 630 patients

Sex: All

Ages: 75+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
• Aged 75 or older.
• Leaving at home and with home as the planned discharge after the admission.
• At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).

Exclusion criteria

• Patient leaving in a retirement home.
• Patient hospitalized at home.
• Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: None (Open label)

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630 participants in 2 patient groups

Transitional care program.

Experimental group

Description:

The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge.

Treatment:

Other: Transitional care program.

standard care program

Other group

Description:

No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention).

Treatment:

Other: standard care program