Trial Outcomes & Findings for Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence (NCT NCT02354482)

NCT ID: NCT02354482

Last Updated: 2019-11-26

Results Overview

Readmission to the hospital within 30 days of discharge.

Recruitment status

COMPLETED

Target enrollment

7939 participants

Primary outcome timeframe

30 days post hospital discharge

Results posted on

2019-11-26

Participant Flow

Any individual participant may have experienced more than one intervention.

Participant milestones

Participant milestones
Measure	Participants Receiving Transitional Care Strategies Participants were exposed to one or more of five different transitional care strategies, or were part of a reference group that did not receive a specific transitional care strategy.
Patient Communication and Care STARTED	2158
Patient Communication and Care COMPLETED	2158
Patient Communication and Care NOT COMPLETED	0
Home-Based Trust and Plain Language STARTED	1979
Home-Based Trust and Plain Language COMPLETED	1979
Home-Based Trust and Plain Language NOT COMPLETED	0
Hospital-Based Trust and Plain Language STARTED	2090
Hospital-Based Trust and Plain Language COMPLETED	2090
Hospital-Based Trust and Plain Language NOT COMPLETED	0
Patient/Family Caregiver Assessment STARTED	3093
Patient/Family Caregiver Assessment COMPLETED	3093
Patient/Family Caregiver Assessment NOT COMPLETED	0
Assessment and Teach Back STARTED	508
Assessment and Teach Back COMPLETED	508
Assessment and Teach Back NOT COMPLETED	0
Reference STARTED	2042
Reference COMPLETED	2042
Reference NOT COMPLETED	0

Reasons for withdrawal

Withdrawal data not reported

Baseline Characteristics

Participants may have experienced one or more interventions.

Baseline characteristics by cohort

Baseline characteristics by cohort
Measure	Participants Recieving Transitional Care Strategies n=7939 Participants Participants received one or more of 5 transitional care strategies, or were part of a reference group that received no specific transitional care strategy.
Age, Categorical Patient Communication · <=18 years	0 Participants n=2158 Participants • Participants may have experienced one or more interventions.
Age, Categorical Patient Communication · Between 18 and 65 years	337 Participants n=2158 Participants • Participants may have experienced one or more interventions.
Age, Categorical Patient Communication · >=65 years	1821 Participants n=2158 Participants • Participants may have experienced one or more interventions.
Age, Categorical Home-Based Trust · <=18 years	0 Participants n=1979 Participants • Participants may have experienced one or more interventions.
Age, Categorical Home-Based Trust · Between 18 and 65 years	200 Participants n=1979 Participants • Participants may have experienced one or more interventions.
Age, Categorical Home-Based Trust · >=65 years	1779 Participants n=1979 Participants • Participants may have experienced one or more interventions.
Age, Categorical Hospital-Based Trust · <=18 years	0 Participants n=2090 Participants • Participants may have experienced one or more interventions.
Age, Categorical Hospital-Based Trust · Between 18 and 65 years	172 Participants n=2090 Participants • Participants may have experienced one or more interventions.
Age, Categorical Hospital-Based Trust · >=65 years	1918 Participants n=2090 Participants • Participants may have experienced one or more interventions.
Age, Categorical Patient/Family Caregiver Assessment · <=18 years	0 Participants n=3093 Participants • Participants may have experienced one or more interventions.
Age, Categorical Patient/Family Caregiver Assessment · Between 18 and 65 years	208 Participants n=3093 Participants • Participants may have experienced one or more interventions.
Age, Categorical Patient/Family Caregiver Assessment · >=65 years	2885 Participants n=3093 Participants • Participants may have experienced one or more interventions.
Age, Categorical Assessement and Teach Back · <=18 years	0 Participants n=508 Participants • Participants may have experienced one or more interventions.
Age, Categorical Assessement and Teach Back · Between 18 and 65 years	47 Participants n=508 Participants • Participants may have experienced one or more interventions.
Age, Categorical Assessement and Teach Back · >=65 years	461 Participants n=508 Participants • Participants may have experienced one or more interventions.
Age, Categorical Reference · <=18 years	0 Participants n=2042 Participants • Participants may have experienced one or more interventions.
Age, Categorical Reference · Between 18 and 65 years	336 Participants n=2042 Participants • Participants may have experienced one or more interventions.
Age, Categorical Reference · >=65 years	1706 Participants n=2042 Participants • Participants may have experienced one or more interventions.
Age, Continuous Patient Communication	70.50 years STANDARD_DEVIATION 10.38 • n=2158 Participants • Participants may have received one or more transitional care strategies.
Age, Continuous Home-Based Trust	72.04 years STANDARD_DEVIATION 9.64 • n=1979 Participants • Participants may have received one or more transitional care strategies.
Age, Continuous Hospital-Based Trust	72.62 years STANDARD_DEVIATION 9.34 • n=2090 Participants • Participants may have received one or more transitional care strategies.
Age, Continuous Patient/Family Caregiver Assessment	73.55 years STANDARD_DEVIATION 9.04 • n=3093 Participants • Participants may have received one or more transitional care strategies.
Age, Continuous Assessment and Teach Back	72.42 years STANDARD_DEVIATION 8.91 • n=508 Participants • Participants may have received one or more transitional care strategies.
Age, Continuous Reference	71.69 years STANDARD_DEVIATION 11.17 • n=2042 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Patient Communication · Female	1093 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Patient Communication · Male	1065 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Home-Based Trust · Female	1102 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Home-Based Trust · Male	877 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Hospital-Based Trust · Female	1082 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Hospital-Based Trust · Male	1008 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Patient/Family Caregiver Assessment · Female	1636 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Patient/Family Caregiver Assessment · Male	1457 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Assessment and Teach Back · Female	268 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Assessment and Teach Back · Male	240 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Reference · Female	1093 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Sex: Female, Male Reference · Male	949 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient Communication · Hispanic or Latino	243 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient Communication · Not Hispanic or Latino	1809 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient Communication · Unknown or Not Reported	106 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Home-Based Trust · Hispanic or Latino	250 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Home-Based Trust · Not Hispanic or Latino	1627 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Home-Based Trust · Unknown or Not Reported	102 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Hospital-Based Trust · Hispanic or Latino	445 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Hospital-Based Trust · Not Hispanic or Latino	1539 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Hospital-Based Trust · Unknown or Not Reported	106 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient/Family Caregive Assessment · Hispanic or Latino	580 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient/Family Caregive Assessment · Not Hispanic or Latino	2345 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Patient/Family Caregive Assessment · Unknown or Not Reported	168 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Assessment and Teach Back · Hispanic or Latino	83 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Assessment and Teach Back · Not Hispanic or Latino	394 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Assessment and Teach Back · Unknown or Not Reported	31 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Reference · Hispanic or Latino	229 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Reference · Not Hispanic or Latino	1643 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Ethnicity (NIH/OMB) Reference · Unknown or Not Reported	170 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · American Indian or Alaska Native	21 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · Asian	46 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · Native Hawaiian or Other Pacific Islander	8 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · Black or African American	141 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · White	1702 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · More than one race	41 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient Communication · Unknown or Not Reported	199 Participants n=2158 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · American Indian or Alaska Native	12 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · Asian	58 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · Native Hawaiian or Other Pacific Islander	5 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · Black or African American	234 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · White	1449 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · More than one race	38 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Home-Based Trust · Unknown or Not Reported	183 Participants n=1979 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · American Indian or Alaska Native	21 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · Asian	87 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · Native Hawaiian or Other Pacific Islander	9 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · Black or African American	155 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · White	1504 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · More than one race	28 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Hospital-Based Trust · Unknown or Not Reported	286 Participants n=2090 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · American Indian or Alaska Native	28 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · Asian	122 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · Native Hawaiian or Other Pacific Islander	19 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · Black or African American	296 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · White	2144 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · More than one race	49 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Patient/Family Caregiver Assessment · Unknown or Not Reported	435 Participants n=3093 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · American Indian or Alaska Native	1 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · Asian	13 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · Native Hawaiian or Other Pacific Islander	1 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · Black or African American	60 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · White	362 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · More than one race	12 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Assessment and Teachback · Unknown or Not Reported	59 Participants n=508 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · American Indian or Alaska Native	15 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · Asian	37 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · Native Hawaiian or Other Pacific Islander	9 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · Black or African American	177 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · White	1577 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · More than one race	28 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.
Race (NIH/OMB) Reference · Unknown or Not Reported	199 Participants n=2042 Participants • Participants may have received one or more transitional care strategies.

PRIMARY outcome

Timeframe: 30 days post hospital discharge

Population: Any individual participant may have experienced more than one group; therefore, the sum of participants across the arms exceeds the total sample size. Results data are shown for the entire arm (overall) and are also broken down into subgroups.

Readmission to the hospital within 30 days of discharge.

Outcome measures

Outcome measures
Measure	Patient Communication and Care Management n=2158 Participants Participants received one more transitional care strategies. 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	Home-Based Trust, Plain Language, and Coordination n=1979 Participants Participants received one more transitional care strategies. 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	Hospital-Based Trust, Plain Language, and Coordination n=2090 Participants Participants received one more transitional care strategies. 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	Patient/Family Caregiver Assessment and Information Exchange a n=3093 Participants Participants received one more transitional care strategies. Patient/Family Caregiver Assessment and Information Exchange among Providers: 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 n=508 Participants Participants received one more transitional care strategies. 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	Reference n=2042 Participants Participants were not involved in a specific transitional care strategy. Standard of Care: No specific Transitional Care Strategy
Hospital Readmission Overall	.956 odds ratio Interval 0.753 to 1.214	.949 odds ratio Interval 0.725 to 1.242	.698 odds ratio Interval 0.538 to 0.905	.972 odds ratio Interval 0.697 to 1.356	1.56 odds ratio Interval 0.94 to 2.59	.964 odds ratio Interval 0.723 to 1.286
Hospital Readmission Multiple Chronic Conditions	.894 odds ratio Interval 0.694 to 1.152	.977 odds ratio Interval 0.756 to 1.264	.848 odds ratio Interval 0.66 to 1.089	1.009 odds ratio Interval 0.787 to 1.293	1.137 odds ratio Interval 0.778 to 1.66	.85 odds ratio Interval 0.625 to 1.155
Hospital Readmission Mental Health Issues	1.075 odds ratio Interval 0.64 to 1.804	.787 odds ratio Interval 0.466 to 1.329	.63 odds ratio Interval 0.372 to 1.066	.736 odds ratio Interval 0.416 to 1.3	1.421 odds ratio Interval 0.579 to 3.486	.636 odds ratio Interval 0.335 to 1.209
Hospital Readmission Rural Area Domicile	.885 odds ratio Interval 0.479 to 1.635	.776 odds ratio Interval 0.455 to 1.325	.777 odds ratio Interval 0.435 to 1.387	1.021 odds ratio Interval 0.511 to 2.039	.122 odds ratio Interval 0.013 to 1.159	.665 odds ratio Interval 0.334 to 1.325
Hospital Readmission Low Health Literacy	1.113 odds ratio Interval 0.776 to 1.595	1.129 odds ratio Interval 0.771 to 1.652	.681 odds ratio Interval 0.471 to 0.984	.916 odds ratio Interval 0.603 to 1.392	1.057 odds ratio Interval 0.575 to 1.941	.927 odds ratio Interval 0.61 to 1.409
Hospital Readmission Medicare/Medicaid Dual Eligible	1.133 odds ratio Interval 0.672 to 1.911	.687 odds ratio Interval 0.39 to 1.211	.706 odds ratio Interval 0.41 to 1.215	.889 odds ratio Interval 0.485 to 1.63	1.357 odds ratio Interval 0.625 to 2.946	.59 odds ratio Interval 0.316 to 1.101
Hospital Readmission Disabled, <65	1.066 odds ratio Interval 0.574 to 1.979	.855 odds ratio Interval 0.454 to 1.609	.960 odds ratio Interval 0.519 to 1.773	1.639 odds ratio Interval 0.826 to 3.255	1.192 odds ratio Interval 0.427 to 3.327	1.031 odds ratio Interval 0.491 to 2.164

PRIMARY outcome

Timeframe: 30 days post hospital discharge

Visit to the ED within 30 days of hospital discharge.