PATient Navigator to rEduce Readmissions

Study Results

Results available

Outcome measurements, participant flow, baseline characteristics, and adverse events have been published for this study.

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Basic Information

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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

1029 participants

Study Classification

INTERVENTIONAL

Study Start Date

2014-07-31

Study Completion Date

2016-10-31

Brief Summary

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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.

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Detailed Description

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Conditions

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Chronic Obstructive Pulmonary Disease Heart Failure Sickle Cell Disease Myocardial Infarction Pneumonia

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

HEALTH_SERVICES_RESEARCH

Blinding Strategy

SINGLE

Outcome Assessors

Study Groups

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Usual Care

Hospital usual care

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

Group Type OTHER

Hospital usual care

Intervention Type BEHAVIORAL

Written discharge instructions provided to patients prior to hospital discharge.

Usual Care + PArTNER

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.

Group Type EXPERIMENTAL

Hospital usual care

Intervention Type BEHAVIORAL

Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention

Intervention Type BEHAVIORAL

A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team

Peer-led telephone support line

Intervention Type BEHAVIORAL

The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Interventions

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Hospital usual care

Written discharge instructions provided to patients prior to hospital discharge.

Intervention Type BEHAVIORAL

Navigator intervention

A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team

Intervention Type BEHAVIORAL

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.

Intervention Type BEHAVIORAL

Eligibility Criteria

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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

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No