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
58 participants
INTERVENTIONAL
2015-06-01
2017-10-01
Brief Summary
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The purpose of this study is to compare the effectiveness of three hospital discharge follow-up methods:
1. standard of care,
2. a nurse telephone intervention (care coordination and education), and
3. an in-home community health worker intervention (care coordination and education).
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Detailed Description
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Conditions
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Study Design
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RANDOMIZED
PARALLEL
HEALTH_SERVICES_RESEARCH
NONE
Study Groups
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Control Group
Survey assessments as well as collection of medical records and billing information.
Surveys
The following information will be collected: demographics, literacy screener, depression screener, medication adherence, self-efficacy, tobacco use, patient activation, health questionnaire, eating patterns, diabetes self-management assessment, stages of change questionnaire, vitals, and self-care behaviors.
Telephonic Nurse Intervention
Survey assessments as well as collection of medical records and billing information. A nurse will communicate with participants via telephone to support diabetes self-management practices.
Surveys
The following information will be collected: demographics, literacy screener, depression screener, medication adherence, self-efficacy, tobacco use, patient activation, health questionnaire, eating patterns, diabetes self-management assessment, stages of change questionnaire, vitals, and self-care behaviors.
Telephonic Nurse Intervention
A nurse will contact patients by phone at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.
In-person Community Health Worker Intervention
Survey assessments as well as collection of medical records and billing information. A community health worker will work with participants in person to support diabetes self-management practices.
Surveys
The following information will be collected: demographics, literacy screener, depression screener, medication adherence, self-efficacy, tobacco use, patient activation, health questionnaire, eating patterns, diabetes self-management assessment, stages of change questionnaire, vitals, and self-care behaviors.
In-person Community Health Worker
An in-person Community Health Worker will contact patients in-person at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.
Interventions
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Surveys
The following information will be collected: demographics, literacy screener, depression screener, medication adherence, self-efficacy, tobacco use, patient activation, health questionnaire, eating patterns, diabetes self-management assessment, stages of change questionnaire, vitals, and self-care behaviors.
Telephonic Nurse Intervention
A nurse will contact patients by phone at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.
In-person Community Health Worker
An in-person Community Health Worker will contact patients in-person at least weekly for month 1 and at least every other week for months 2 and 3 and will collect the following information: medication adherence, discharge plan adherence, problem solving, diet and physical activity issues and to assess self-management, dietary, and physical activity improvements. In addition the nurse will link participants with resources.
Eligibility Criteria
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Inclusion Criteria
* between 18 and 75 years of age
* a patient discharged from the Regional Medical Center emergency department or Regional Medical Center hospital within 72 hours prior to consent
* diagnosed with diabetes or at high risk for diabetes
* will be a Regional Medical Center patient for follow-up care
* speaks English
* has access to a phone
Stage 2 Recruitment:
Exclusion Criteria
* terminal illness (e.g., advanced cancer, end-stage chronic obstructive pulmonary disease, advanced dementia)
* incarceration
* resident in a skilled nursing home.
18 Years
75 Years
ALL
No
Sponsors
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University of North Carolina, Chapel Hill
OTHER
South Carolina Department of Health and Human Services
UNKNOWN
North Carolina Translational and Clinical Sciences Institute
OTHER
The Regional Medical Center of Orangeburg and Calhoun Counties
UNKNOWN
Medical University of South Carolina
OTHER
Responsible Party
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Principal Investigators
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Carolyn Jenkins, DrPh, MSN
Role: PRINCIPAL_INVESTIGATOR
Medical University of South Carolina
Samuel Cykert, MD
Role: PRINCIPAL_INVESTIGATOR
University of North Carolina, Chapel Hill
Locations
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The Regional Medical Center of Orangeburg and Calhoun Counties
Orangeburg, South Carolina, United States
Countries
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Other Identifiers
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Pro00038334
Identifier Type: -
Identifier Source: org_study_id
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