A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
NCT ID: NCT02351648
Last Updated: 2015-01-30
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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COMPLETED
NA
840 participants
INTERVENTIONAL
2012-10-31
2014-12-31
Brief Summary
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Detailed Description
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Primary Aim:
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH
Secondary Aim:
To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)
Conditions
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Keywords
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Study Design
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RANDOMIZED
PARALLEL
HEALTH_SERVICES_RESEARCH
SINGLE
Study Groups
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Intervention'
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge
Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge
Intervention after discharge:
Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
a transitional care model
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge
Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge
Intervention after discharge:
Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
Control'
Patients receive usual standard of care from the internal medicine team
Control
Patients receive usual standard of care from the internal medicine team
Interventions
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a transitional care model
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge
Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge
Intervention after discharge:
Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
Control
Patients receive usual standard of care from the internal medicine team
Eligibility Criteria
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Inclusion Criteria
Exclusion Criteria
* Subject has no local home address
* Subject is from a long-term care facility during index admission
* Subject is unable to participate in telephone surveillance
* Subject is discharged before takeover
* Subject has impaired decision making capacity without surrogate decision maker
* Subject is pending or currently in critical care unit
* Subject or caregiver is mentally unstable
* Subject is haemodynamically unstable
* Subject requires acute inpatient respiratory support
* Subject requires acute inpatient dialysis support
* Subject pending surgical intervention
* Subject pending transfer to other specialist discipline
* Primary team consultant declined to participate in this research
21 Years
ALL
No
Sponsors
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Agency for Integrated Care, Singapore
OTHER
Duke-NUS Graduate Medical School
OTHER
Singapore General Hospital
OTHER
Responsible Party
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Principal Investigators
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Kheng Hock Lee, MBBS
Role: PRINCIPAL_INVESTIGATOR
Singapore General Hospital
Locations
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Singapore General Hospital
Singapore, Singapore, Singapore
Countries
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References
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Coleman EA, Smith JD, Frank JC, Eilertsen TB, Thiare JN, Kramer AM. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02. doi: 10.5334/ijic.60. Epub 2002 Jun 1.
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003 Feb 4;138(3):161-7. doi: 10.7326/0003-4819-138-3-200302040-00007.
Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD004510. doi: 10.1002/14651858.CD004510.pub3.
Other Identifiers
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2012/848/E
Identifier Type: -
Identifier Source: org_study_id