The Care Transitions Intervention

Sponsor

University of Colorado, Denver (Other)

Overall Status

Completed

CT.gov ID

NCT00244491

Collaborator

The John A. Hartford Foundation (Other)

1,400

Enrollment

Location

Duration (Months)

127.6

Patients Per Site Per Month

Study Details

Study Description

Brief Summary

This intervention tests whether encouraging older patients and their caregivers to assert a more active role in their care transitions could improve clinical outcomes. Patients are supported by a nurse transition coach and specific tools, including a Personal Health Record.

Condition or Disease	Intervention/Treatment	Phase
Continuity of Patient Care	Behavioral: Care Transitions Intervention	N/A

Detailed Description

See above.

Study Design

Study Type:

Interventional

Allocation:

Randomized

Intervention Model:

Single Group Assignment

Masking:

None (Open Label)

Official Title:

The Care Transitions Intervention

Study Start Date :

Sep 1, 2002

Study Completion Date :

Aug 1, 2003

Outcome Measures

Primary Outcome Measures

Rehospitalization rate at 30, 90 and 180 days after index hospitalization. []

Secondary Outcome Measures

Rehospitalization rate at 30, 90 and 180 days after index hospitalization. Rehospitalization for the same condition as the index hospital stay, at 30, 90 and 180 days. []

Eligibility Criteria

Criteria

Ages Eligible for Study:

65 Years and Older

Sexes Eligible for Study:

All

Accepts Healthy Volunteers:

Inclusion Criteria:

To be eligible for this study, patients from the participating delivery system had to:

be age 65 years or older, 2) be admitted to one of the participating delivery system's contract hospitals during the study period for a non-psychiatrically-related condition, 3) be community-dwelling (i.e., not from a long-term care facility), 4) reside within a predefined geographic radius of the hospital (thereby making a home visit feasible), 5) have a working telephone, 6) be English-speaking, 7) show no documentation of dementia in the medical record, 8) have no plans to enter hospice, 9) not be participating in another research protocol, and 10) have documented in their medical record at least one of 11 diagnoses, including stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, or pulmonary embolism.