PATient Navigator to rEduce Readmissions (PArTNER)

University of Illinois

Status: Completed

Conditions: Chronic Obstructive Pulmonary Disease; Myocardial Infarction; Pneumonia; Sickle Cell Disease; Heart Failure

Treatments: Behavioral: Navigator intervention; Behavioral: Hospital usual care; Behavioral: Peer-led telephone support line

Study type: Interventional

Funder types: Other

Identifiers

NCT02114515

PCORI-IH 1211-4365

Details and patient eligibility

About

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Enrollment: 1,029 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

1. Age 18 years or older on date of hospital admission
2. Hospitalized at the University of Illinois Hospital, Chicago
3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
4. Receive medical care on an inpatient medical service

Exclusion criteria

1. Unable to understand and speak English
2. Unable/decline to give informed consent
3. Previous participant in PArTNER
4. Planned transfer to another acute care facility
5. Planned discharge to facility other than home (e.g. long term care facility)
6. Currently on hospice or plans to discharge home to hospice
7. Current plans to leave against medical advice

Trial design

Primary purpose: Health Services Research

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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1,029 participants in 2 patient groups

Usual Care

Other group

Description:

Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Treatment:

Behavioral: Hospital usual care

Usual Care + PArTNER

Experimental group

Description:

Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Treatment:

Behavioral: Navigator intervention

Behavioral: Peer-led telephone support line

Behavioral: Hospital usual care