PArTNER: PATient Navigator to rEduce Readmissions

• Sponsor: University of Illinois at Chicago (Other)
• Overall Status: Completed
• CT.gov ID: NCT02114515
• Collaborator: Patient-Centered Outcomes Research Institute (Other), Society of Hospital Medicine (Other), COPD Foundation (Other), University of Kentucky (Other), Mended Hearts (Other), American Heart Association (Other), Sickle Cell Disease Association of Illinois (Other), AcademyHealth (Other), The National Association of Social Workers Foundation (Other), Respiratory Health Association (Other), University of Illinois Sickle Cell Patient Council (Other), National Jewish Health (Other), Baystate Medical Center (Other)
• Enrollment: 1,029
• Location: 1
• Arms: 2
• Duration (Months): 27
• Patients Per Site Per Month: 38.1

Study Details

Study Description

Brief Summary

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Condition or Disease	Intervention/Treatment	Phase
Chronic Obstructive Pulmonary Disease; Heart Failure; Sickle Cell Disease; Myocardial Infarction; Pneumonia	Behavioral: Hospital usual care; Behavioral: Navigator intervention; Behavioral: Peer-led telephone support line	N/A

Study Design

• Study Type: Interventional
• Actual Enrollment: 1029 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: Single (Outcomes Assessor)
• Primary Purpose: Health Services Research
• Official Title: PATient Navigator to rEduce Readmissions
• Study Start Date: Jul 1, 2014
• Actual Primary Completion Date: Oct 1, 2016
• Actual Study Completion Date: Oct 1, 2016

Arms and Interventions

Arm	Intervention/Treatment
Other: Usual Care Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Behavioral: Hospital usual care; Written discharge instructions provided to patients prior to hospital discharge.
Experimental: Usual Care + PArTNER Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.	Behavioral: Hospital usual care; Written discharge instructions provided to patients prior to hospital discharge.; Behavioral: Navigator intervention; A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team; Behavioral: Peer-led telephone support line; The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Outcome Measures

Primary Outcome Measures

1. PROMIS Emotional Distress-Anxiety (v1.0, SF4a) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.

2. PROMIS Informational Support (v2.0, SF4a) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Secondary Outcome Measures

1. PROMIS Emotional Support (v2.0, SF4a) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

2. PROMIS Instrumental Support (v2.0, SF4a) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

3. PROMIS Global Health, Physical (v1.1, SF) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

4. PROMIS Global Health, Mental (v1.1, SF) [30 days post discharge]

   Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

5. PROMIS Emotional Distress-Anxiety (v1.0, SF4a) [60 days post discharge]

   Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.

6. PROMIS Informational Support (v2.0, SF4a) [60 days post discharge]

   Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

7. PROMIS Emotional Support (v2.0, SF4a) [60 days post discharge]

   Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

8. PROMIS Instrumental Support (v2.0, SF4a) [60 days post discharge]

   Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

9. PROMIS Global Health, Physical (v1.1, SF) [60 days post discharge]

   Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

10. PROMIS Global Health, Mental (v1.1, SF) [60 days post discharge]

    Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

11. Death [30 days post discharge]

    Caregiver-reported and confirmed by EHR review

12. Death [60 days post discharge]

    Caregiver-reported and confirmed by EHR review

13. Re-hospitalization or Death [30 days post discharge]

    Confirmed by EHR review

14. Re-hospitalization or Death [60 days post discharge]

    Confirmed by EHR review

15. ED Visit, Re-hospitalization, or Death [30 days post discharge]

    Confirmed by EHR review

16. ED Visit, Re-hospitalization, or Death [60 days post discharge]

    Confirmed by EHR review

17. Outpatient Healthcare Visit [14 days post discharge]

    Self-reported

18. Outpatient Healthcare Visit [14 days post discharge]

    EHR-reported

Eligibility Criteria

Criteria

• Ages Eligible for Study: 18 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

1. Age 18 years or older on date of hospital admission

2. Hospitalized at the University of Illinois Hospital, Chicago

3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction

4. Receive medical care on an inpatient medical service

Exclusion Criteria:

1. Unable to understand and speak English

2. Unable/decline to give informed consent

3. Previous participant in PArTNER

4. Planned transfer to another acute care facility

5. Planned discharge to facility other than home (e.g. long term care facility)

6. Currently on hospice or plans to discharge home to hospice

7. Current plans to leave against medical advice

Contacts and Locations

Locations

	Site	City	State	Country	Postal Code
1	University of Illinois Hospital	Chicago	Illinois	United States	60612

Sponsors and Collaborators

• University of Illinois at Chicago
• Patient-Centered Outcomes Research Institute
• Society of Hospital Medicine
• COPD Foundation
• University of Kentucky
• Mended Hearts
• American Heart Association
• Sickle Cell Disease Association of Illinois
• AcademyHealth
• The National Association of Social Workers Foundation
• Respiratory Health Association
• University of Illinois Sickle Cell Patient Council
• National Jewish Health
• Baystate Medical Center

Investigators

• Principal Investigator: Jerry A Krishnan, MD, PhD, University of Illinois at Chicago
• Principal Investigator: Elizabeth Calhoun, PhD, University of Arizona
• Principal Investigator: Mark V. Williams, MD, University of Kentucky

Study Documents (Full-Text)

None provided.

More Information

Additional Information:

• Patient-Centered Outcomes Research Institute (PCORI): Funding Award details

Publications

None provided.

• Responsible Party: Jerry Krishnan, Professor of Medicine and Public Health; Associate Vice Chancellor for Population Health Sciences, University of Illinois at Chicago
• ClinicalTrials.gov Identifier: NCT02114515
• Other Study ID Numbers: PCORI-IH 1211-4365
• First Posted: Apr 15, 2014
• Last Update Posted: Feb 15, 2019
• Last Verified: Oct 1, 2018

• Keywords provided by Jerry Krishnan, Professor of Medicine and Public Health; Associate Vice Chancellor for Population Health Sciences, University of Illinois at Chicago: Patient Navigators; Readmissions; Peer Coaching
• Additional relevant MeSH terms: Lung Diseases, Obstructive; Pulmonary Disease, Chronic Obstructive; Myocardial Infarction; Anemia, Sickle Cell; Infarction

Study Results

Participant Flow

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Period Title: Overall Study
STARTED	511	518
COMPLETED	378	368
NOT COMPLETED	133	150

Baseline Characteristics

Arm/Group Title	Usual Care	Usual Care + PArTNER	Total
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.	Total of all reporting groups
Overall Participants	511	518	1029
Age (Count of Participants)
<=18 years	0 0%	0 0%	0 0%
Between 18 and 65 years	412 80.6%	423 81.7%	835 81.1%
>=65 years	99 19.4%	95 18.3%	194 18.9%
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	49.9 (17.0)	49.8 (16.5)	49.9 (16.8)
Sex: Female, Male (Count of Participants)
Female	290 56.8%	277 53.5%	567 55.1%
Male	221 43.2%	241 46.5%	462 44.9%
Ethnicity (NIH/OMB) (Count of Participants)
Hispanic or Latino	40 7.8%	49 9.5%	89 8.6%
Not Hispanic or Latino	471 92.2%	468 90.3%	939 91.3%
Unknown or Not Reported	0 0%	1 0.2%	1 0.1%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	1 0.2%	3 0.6%	4 0.4%
Asian	4 0.8%	6 1.2%	10 1%
Native Hawaiian or Other Pacific Islander	0 0%	0 0%	0 0%
Black or African American	424 83%	423 81.7%	847 82.3%
White	62 12.1%	72 13.9%	134 13%
More than one race	7 1.4%	4 0.8%	11 1.1%
Unknown or Not Reported	13 2.5%	10 1.9%	23 2.2%
Region of Enrollment (participants) [Number]
United States	511 100%	518 100%	1029 100%

Outcome Measures

1. Primary Outcome

Title	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	406	391
Mean (Standard Error) [T-score]	-0.2 (0.5)	-1.7 (0.5)

2. Primary Outcome

Title	PROMIS Informational Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	405	391
Mean (Standard Error) [T-score]	2.3 (0.6)	2.5 (0.6)

3. Secondary Outcome

Title	PROMIS Emotional Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	401	390
Mean (Standard Error) [T-score]	-0.1 (0.5)	-0.1 (0.5)

4. Secondary Outcome

Title	PROMIS Instrumental Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	403	391
Mean (Standard Error) [T-score]	1.0 (0.5)	0.6 (0.5)

5. Secondary Outcome

Title	PROMIS Global Health, Physical (v1.1, SF)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	408	389
Mean (Standard Error) [T-score]	4.6 (0.4)	4.4 (0.4)

6. Secondary Outcome

Title	PROMIS Global Health, Mental (v1.1, SF)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	408	389
Mean (Standard Error) [T-score]	0.8 (0.4)	0.6 (0.4)

7. Secondary Outcome

Title	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	375	365
Mean (Standard Error) [T-score]	0.3 (0.6)	-1.1 (0.6)

8. Secondary Outcome

Title	PROMIS Informational Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	373	363
Mean (Standard Error) [T-score]	1.7 (0.6)	2.0 (0.7)

9. Secondary Outcome

Title	PROMIS Emotional Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	372	363
Mean (Standard Error) [T-score]	0.1 (0.5)	-0.2 (0.5)

10. Secondary Outcome

Title	PROMIS Instrumental Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	374	363
Mean (Standard Error) [T-score]	0.8 (0.5)	1.0 (0.5)

11. Secondary Outcome

Title	PROMIS Global Health, Physical (v1.1, SF)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	372	365
Mean (Standard Error) [T-score]	3.4 (0.5)	3.6 (0.4)

12. Secondary Outcome

Title	PROMIS Global Health, Mental (v1.1, SF)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	372	366
Mean (Standard Error) [T-score]	-1.3 (0.5)	01.1 (0.4)

13. Secondary Outcome

Title	Death
Description	Caregiver-reported and confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	502	497
Count of Participants [Participants]	4 0.8%	7 1.4%

14. Secondary Outcome

Title	Death
Description	Caregiver-reported and confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	493	488
Count of Participants [Participants]	9 1.8%	9 1.7%

15. Secondary Outcome

Title	Re-hospitalization or Death
Description	Confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	503	495
Count of Participants [Participants]	100 19.6%	112 21.6%

16. Secondary Outcome

Title	Re-hospitalization or Death
Description	Confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	493	487
Count of Participants [Participants]	147 28.8%	159 30.7%

17. Secondary Outcome

Title	ED Visit, Re-hospitalization, or Death
Description	Confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	503	495
Count of Participants [Participants]	156 30.5%	154 29.7%

18. Secondary Outcome

Title	ED Visit, Re-hospitalization, or Death
Description	Confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	494	487
Count of Participants [Participants]	210 41.1%	216 41.7%

19. Secondary Outcome

Title	Outpatient Healthcare Visit
Description	Self-reported
Time Frame	14 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	405	388
Count of Participants [Participants]	137 26.8%	112 21.6%

20. Secondary Outcome

Title	Outpatient Healthcare Visit
Description	EHR-reported
Time Frame	14 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Measure Participants	511	507
Count of Participants [Participants]	236 46.2%	232 44.8%

Adverse Events

Time Frame	Adverse event data were collected from enrollment through 60 days after hospital discharge.
Arm/Group Title	Usual Care		Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.		Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
All Cause Mortality
	Usual Care		Usual Care + PArTNER
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	12/511 (2.3%)		12/518 (2.3%)
Serious Adverse Events
	Usual Care		Usual Care + PArTNER
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	12/511 (2.3%)		12/518 (2.3%)
General disorders
All-cause death	12/511 (2.3%)		12/518 (2.3%)
Other (Not Including Serious) Adverse Events
	Usual Care		Usual Care + PArTNER
	Affected / at Risk (%)	# Events	Affected / at Risk (%)	# Events
Total	0/511 (0%)		0/518 (0%)

Limitations/Caveats

No limitations or caveats to report.

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.