Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

Study Results

Results available

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

View full results

Basic Information

Get a concise snapshot of the trial, including recruitment status, study phase, enrollment targets, and key timeline milestones.

Recruitment Status

COMPLETED

Total Enrollment

7939 participants

Study Classification

OBSERVATIONAL

Study Start Date

2015-03-31

Study Completion Date

2019-06-30

Brief Summary

Review the sponsor-provided synopsis that highlights what the study is about and why it is being conducted.

Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.

Related Clinical Trials

Explore similar clinical trials based on study characteristics and research focus.

Communication During Hospitalization About Resuscitation Trial

NCT02984124

Severe Life-limiting COPD Severe Life-limiting Heart Failure Severe Life-limiting Cirrhosis +3 more

ACTIVE_NOT_RECRUITING PHASE2/PHASE3

Comparing Methods for Tracking Health Information at Home After Lung Transplant

NCT00818025

Lung Disease

COMPLETED NA

Provider-Patient Communication Coaching

NCT02783742

Provider Burnout Communication

COMPLETED NA

Increasing Adherence to Treatment Recommendations Following a Cardiac Event

NCT02327260

Cardiovascular Disease

COMPLETED NA

Bringing I-PASS to the Bedside: A Communication Bundle to Improve Patient Safety and Experience

NCT02320175

Communication

COMPLETED NA

Detailed Description

Dive into the extended narrative that explains the scientific background, objectives, and procedures in greater depth.

Patients in the U.S. suffer harm too often as they move between sites of health care, and their caregivers experience significant burden. Unfortunately, the usual approach to health care does not support continuity and coordination during such "care transitions" between hospitals, clinics, home or nursing homes. Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and ER visits.

Specific Aims:

1. Identify the transitional care outcomes and components that matter most to patients and caregivers.
2. Determine which evidence-based transitional care components (TCCs) or clusters most effectively yield patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different types of care settings and communities.
3. Identify barriers and facilitators to the implementation of specific TCCs or clusters of TCCs for different types of care settings and communities.
4. Develop recommendations for dissemination and implementation of the findings on the best evidence regarding how to achieve optimal TC services and outcomes for patients, caregivers and providers.

Study Design:

Capitalizing on the opportunity for a natural experiment observational study, the research team will conduct qualitative and quantitative studies. This 52-month study is divided into two distinct phases. During the first phase, Project ACHIEVE will use focus groups, with patients, caregivers, providers, and site visits to identify the transitional care outcomes and service components that matter most to patients. In this first phase, based on this information and an extensive evidence-based review of the research literature, the ACHIEVE team will develop surveys to be administrated in Phase II. The project team will conduct mail and phone surveys of patients and caregivers recruited from approximately 45 hospitals across the U.S. to assess what transitional care services patients and caregivers experience and how they are associated with outcomes. Additionally, the project team will conduct healthcare provider surveys and site visits to assess the facilitators and barriers to implementing transitional care strategies, organizational contexts (leadership and physician engagement, change culture, etc.), and community collaboration.

Outcomes and Impact:

Through rigorous study and evaluation, Project ACHIEVE will:

1. Identify best practices in care transitions that matter most to patients and their caregivers, and reduce excess emergency department and hospital utilization.
2. Develop a toolkit to guide informed decisions and spread these best practices across the U.S.
3. Develop Care Transitions Surveys that can standardize evaluation of patients' and caregivers' experience with care transitions.

Conditions

See the medical conditions and disease areas that this research is targeting or investigating.

Care Transitions

Study Design

Understand how the trial is structured, including allocation methods, masking strategies, primary purpose, and other design elements.

Observational Model Type

COHORT

Study Time Perspective

PROSPECTIVE

Study Groups

Review each arm or cohort in the study, along with the interventions and objectives associated with them.

Diverse, high-risk patient populations

Patient Communication and Care Management

Intervention Type BEHAVIORAL

Received the following Transitional Care strategies:

1. Helpful Health Care Contact OR Symptom Management
2. Post-discharge Care Consultation
3. Patient Goal/Preference Assessment
4. Plain Language Communication in Hospital
5. Plain Language Communication at Home
6. Transition Summary for Patients and Family Caregivers

Home-Based Trust, Plain Language, and Coordination

Intervention Type BEHAVIORAL

Received the following Transitional Care Strategies:

1. Transition Team
2. Home visits
3. Plain Language Communication at Home
4. Promote Trust at Home
5. Referral to Community Services
6. Follow-up Appointment

Hospital-Based Trust, Plain Language, and Coordination

Intervention Type BEHAVIORAL

Received the following Transitional Care Strategies:

1. Post-discharge care consultation
2. Identify High-Risk Patients and Intervene
3. Medication Reconciliation
4. Plain Language Communication in Hospital
5. Promote Trust in the Hospital
6. Transition Summary for Patients and Family Caregivers

Patient/Caregiver Assessment and Provider Information Exchange

Intervention Type BEHAVIORAL

Received the following Transitional Care Strategies:

1. Patient Goal/Preference Assessment
2. Identify High-Risk Patients and Intervene
3. Timely Exchange of Critical Patient Information among Providers
4. Patient/Family Caregiver Transitional Care Needs Assessment

Assessment and Teach Back

Intervention Type BEHAVIORAL

Received the following Transitional Care Strategies:

1. Post-discharge care consultation
2. Language Assessment
3. Teach Back for Information and Skills

Standard of Care (Reference)

Intervention Type OTHER

No specific Transitional Care Strategy

Interventions

Learn about the drugs, procedures, or behavioral strategies being tested and how they are applied within this trial.

Patient Communication and Care Management

Received the following Transitional Care strategies:

1. Helpful Health Care Contact OR Symptom Management
2. Post-discharge Care Consultation
3. Patient Goal/Preference Assessment
4. Plain Language Communication in Hospital
5. Plain Language Communication at Home
6. Transition Summary for Patients and Family Caregivers

Intervention Type BEHAVIORAL

Home-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies:

1. Transition Team
2. Home visits
3. Plain Language Communication at Home
4. Promote Trust at Home
5. Referral to Community Services
6. Follow-up Appointment

Intervention Type BEHAVIORAL

Hospital-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies:

1. Post-discharge care consultation
2. Identify High-Risk Patients and Intervene
3. Medication Reconciliation
4. Plain Language Communication in Hospital
5. Promote Trust in the Hospital
6. Transition Summary for Patients and Family Caregivers

Intervention Type BEHAVIORAL

Patient/Caregiver Assessment and Provider Information Exchange

Received the following Transitional Care Strategies:

1. Patient Goal/Preference Assessment
2. Identify High-Risk Patients and Intervene
3. Timely Exchange of Critical Patient Information among Providers
4. Patient/Family Caregiver Transitional Care Needs Assessment

Intervention Type BEHAVIORAL

Assessment and Teach Back

Received the following Transitional Care Strategies:

1. Post-discharge care consultation
2. Language Assessment
3. Teach Back for Information and Skills

Intervention Type BEHAVIORAL

Standard of Care (Reference)

No specific Transitional Care Strategy

Intervention Type OTHER

Eligibility Criteria

Check the participation requirements, including inclusion and exclusion rules, age limits, and whether healthy volunteers are accepted.

Inclusion Criteria

* diverse high risk patient populations, including those with:

1. multiple chronic conditions
2. mental health issues
3. rural area domicile
4. limited English proficiency or low health literacy
5. low socioeconomic status
6. Medicare and Medicaid dual eligible
7. disabled and younger than 65.

Exclusion Criteria

* children
* non-Medicare patients
* Under police custody
* Under suicide watch
* In-hospital death
* Transferred (not discharged) to another acute care hospital
* Discharged against medical advice
* Admission for primary diagnosis of psychiatric conditions
* Admission for rehabilitation
* Admission for medical treatment of cancer

Minimum Eligible Age

18 Years

Eligible Sex

ALL

Accepts Healthy Volunteers

No