Reducing Readmission Rates by Providing a Comprehensive Transition Plan From Hospital to Home for Cardiac Surgery Patients.

Study Results

Results pending

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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Recruitment Status

COMPLETED

Clinical Phase

NA

Total Enrollment

450 participants

Study Classification

INTERVENTIONAL

Study Start Date

2016-05-23

Study Completion Date

2020-03-26

Brief Summary

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Patients who undergo cardiac surgery will be screened by a team member with the risk score once the patient has been admitted to the Cardiovascular Progressive Care Unit (CVPCU) after surgery. Participants will be randomized to the intervention or the control group. Both groups will receive standard discharge planning. In addition, the intervention group will have a nurse practitioner (NP) who will be responsible to verify that each essential step of the discharge process has been completed and will visit the patient in patient's home after discharge to complete a physical, review medications, titrate medications as needed, prescribe any necessary treatments, and perform education. The primary outcome variable will be a decrease in the 30 day readmission rate comparing high risk patients at pre and post intervention.

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Detailed Description

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Conditions

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Cardiac Surgery

Study Design

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Allocation Method

RANDOMIZED

Intervention Model

PARALLEL

Primary Study Purpose

SUPPORTIVE_CARE

Blinding Strategy

NONE

Study Groups

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Home visit group

Will receive a home visit after discharge in addition to the standard discharge planning.

Group Type EXPERIMENTAL

Home Visit

Intervention Type BEHAVIORAL

Physical exam, medication dose titration

Control group

Will receive only the standard discharge planning.

Group Type NO_INTERVENTION

No interventions assigned to this group

Interventions

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Home Visit

Physical exam, medication dose titration

Intervention Type BEHAVIORAL

Eligibility Criteria

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Inclusion Criteria

* All patients 18 years of age or greater who have had cardiac surgery procedures including coronary artery bypass surgery (CABG), valve replacement, aortic aneurysm repair, and combined CABG and valve procedures.

Exclusion Criteria

* Patients who have undergone orthotopic heart transplantation, orthotopic lung transplantation, or orthotopic heart-lung transplantation
* Patients who have undergone ventricular assist device placement
* Patients who do not reside in Maryland
* Non English speaking patients
* Patients discharged to a facility.

Eligible Sex

ALL

Accepts Healthy Volunteers

Yes