Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward

NCT ID: NCT02421133

Last Updated: 2025-12-19

Basic Information

• Recruitment Status: COMPLETED
• Clinical Phase: NA
• Total Enrollment: 630 participants
• Study Classification: INTERVENTIONAL
• Study Start Date: 2015-07-31
• Study Completion Date: 2016-11-30

Brief Summary

In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.

Detailed Description

The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,

Conditions

Geriatrics

Keywords

Care transition program; Patient readmission; Transition Nurse; Stepped wedge; elderly

Study Design

• Allocation Method: RANDOMIZED
• Intervention Model: PARALLEL
• Primary Study Purpose: HEALTH_SERVICES_RESEARCH
• Blinding Strategy: NONE

Study Groups

Transitional care program.

The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge.

Group Type: EXPERIMENTAL

Transitional care program.

Intervention Type: OTHER

During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge.

The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring.

During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.

standard care program

No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention).

Group Type: OTHER

standard care program

Intervention Type: OTHER

The patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work.

Interventions

Transitional care program.

During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge.

The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring.

During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.

Intervention Type: OTHER

standard care program

The patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work.

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
• Aged 75 or older.
• Leaving at home and with home as the planned discharge after the admission.
• At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).

Exclusion Criteria

• Patient leaving in a retirement home.
• Patient hospitalized at home.
• Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission

• Minimum Eligible Age: 75 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

Hospices Civils de Lyon

OTHER

Sponsor Role: lead

Responsible Party

Responsibility Role: SPONSOR

Principal Investigators

Marc Bonnefoy

Role: PRINCIPAL_INVESTIGATOR

Centre Hospitalier Lyon Sud-Hospices Civils de Lyon

Locations

CH Gériatrique des Monts d'Or

Albigny-sur-Saône, , France

CH Bourg-en-Bresse

Bourg-en-Bresse, , France

Centre Hospitalier Alpes Léman

Contamine-sur-Arve, , France

Hôpital Édouard Herriot

Lyon, , France

Centre Hospitalier Lyon Sud

Pierre-Bénite, , France

CHG Annecy

Pringy, , France

CH Saint-Chamond

Saint-Chamond, , France

Clinique des portes du sud

Vénissieux, , France

CH Villefranche

Villefranche, , France

Countries

France

References

Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016 Mar 3;16:57. doi: 10.1186/s12877-016-0233-2.

Reference Type: RESULT

PMID: 26940678 (View on PubMed)

Other Identifiers

2014.874

Identifier Type: -

Identifier Source: org_study_id