Improving Care Transitions for Medicaid Insured Individuals With Co-occurring Serious Mental Illness (THRIVE-SMI)

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University of Pennsylvania




Care Transitions


Behavioral: Thrive Intervention

Study type


Funder types

Other U.S. Federal agency


1R18HS029815-01 (U.S. AHRQ Grant/Contract)

Details and patient eligibility


This study aims to evaluate the THRIVE clinical pathway at HUP-Cedar, focusing on supporting Medicaid-insured individuals, including those with serious mental illness, following hospitalization. The study will assess clinician/administrator perspectives on the pathway's feasibility, appropriateness, and acceptability and analyze referral patterns and post-discharge outcomes. The objectives are: 1. To conduct a qualitative study evaluating the implementation of THRIVE, particularly its adaptation to include patients with serious mental illness. 2. To examine referral patterns, 30-day readmission rates, and ED utilization for THRIVE participants, comparing them with those receiving standard care. Participants will be referred to home care services during hospitalization and seen by a home care nurse within 48 hours post-discharge. A discharging physician or Advanced Practice Provider will oversee care for 30 days or until a primary care or specialist visit. The Care Coordination Team will hold weekly case conferences for 30 days post-discharge to address both health and mental health needs. The study will compare outcomes of Medicaid-insured patients, including those with serious mental illness, to those receiving usual care.

Full description

Detailed Description: This study is a single-site Type 1 hybrid effectiveness-implementation parallel mixed methods (quantitative + qualitative) quasi-experimental study at HUP-Cedar, focusing on the THRIVE clinical pathway. It integrates simultaneous quantitative and qualitative data collection and analysis, with a stronger emphasis on quantitative data to evaluate referrals, outcomes, and program fidelity. The qualitative aspect will explore the implementation process, delving into the barriers and facilitators encountered by healthcare providers. It will also assess stakeholder perspectives on the intervention's impact on health inequities among Medicaid-insured individuals in both acute and home care settings. By nesting qualitative interviews within a quasi-experimental framework, the study aims to examine the intervention's effect on primary outcomes (homecare referrals, 30-day readmission, ED utilization, connection to PCP) and to identify professional and organizational barriers to its implementation. The combination of effectiveness data with contextual insights will inform understanding of factors critical to THRIVE's implementation and outcomes. Qualitative Study: The recruitment process is meticulously managed to track each participant's journey. Recruitment begins in early January, with participants contacted via email, providing study details and interview scheduling links. Follow-up reminders ensure participant engagement. Interviews, conducted virtually and recorded with consent, focus on maintaining confidentiality and privacy. Non-consented sessions are captured through detailed notes. Post-interview, recordings are transcribed for analysis, enabling categorization into codes and themes for a deeper understanding of participant perspectives. Quantitative Study: Employing a stepped wedge design, the study would begin early March and would involve a randomized training of case managers at HUP-Cedar over several months. Initially, a subset of case managers receives training on the THRIVE pathway and starts offering referrals. After 8 weeks, the remaining case managers are trained and begin making referrals. This staggered approach allows for evaluation of the THRIVE intervention's rollout and its impact on patient care and outcomes.


267 estimated patients




18+ years old


Accepts Healthy Volunteers

Inclusion criteria

  • Medicaid insured
  • Residing in the state of Pennsylvania
  • Experienced a hospitalization at study hospital
  • Agrees to home care at partner home care setting.

Exclusion criteria

  • Individuals under age 18

Trial design

Primary purpose




Interventional model

Parallel Assignment


None (Open label)

267 participants in 2 patient groups

THRIVE Intervention
Experimental group
THRIVE Intervention 1-month intensive post discharge case management and care coordination
Behavioral: Thrive Intervention
Usual Care
No Intervention group
Discharge to home without intensive post-acute case management or care coordination.

Trial contacts and locations



Central trial contact

Kelvin Amenyedor, MD,MPH; Jacqueline M Brooks Carthon, PhD,RN

Data sourced from

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