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Completed

NCT Number: NCT02351648

A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH

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Key information

Conditions

Chronic Diseases Chronic Disease Disease Attributes Pathologic Processes Pathological Conditions, Signs and Symptoms

Age range

21 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

Singapore General Hospital

Singapore, 169608

About this study

Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending

Primary Aim:

To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH

Secondary Aim:

To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)

Who can participate

Healthy volunteers accepted: No

Only the study team can determine whether someone qualifies for participation.

Inclusion criteria

-More than 1 admission in the last 90 days

Exclusion criteria

  • Subject is a non-resident
  • Subject has no local home address
  • Subject is from a long-term care facility during index admission
  • Subject is unable to participate in telephone surveillance
  • Subject is discharged before takeover
  • Subject has impaired decision making capacity without surrogate decision maker
  • Subject is pending or currently in critical care unit
  • Subject or caregiver is mentally unstable
  • Subject is haemodynamically unstable
  • Subject requires acute inpatient respiratory support
  • Subject requires acute inpatient dialysis support
  • Subject pending surgical intervention
  • Subject pending transfer to other specialist discipline
  • Primary team consultant declined to participate in this research

Treatment and study plan

a transitional care model

Other

Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge

Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge

Intervention after discharge:

Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients

Control

Other

Patients receive usual standard of care from the internal medicine team

Primary outcomes

  1. Readmission rate

    Time frame: 30 days after index discharge

    A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients

Secondary outcomes

  1. Readmission rate

    Time frame: up to 180 days after index discharge

    Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge

  2. Quality of transitional care using a validated care transition measure (CTM-15) tool

    Time frame: 90 days after index discharge

    Care transition measure survey of subjects

  3. Emergency department attendance rate

    Time frame: Up to 180 days after index discharge

    Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge

  4. Time to first readmission

    Time frame: Up to 90 days after index discharge

    Censored time to readmission for both intervention and control group

  5. Specialist Outpatient Clinic visits

    Time frame: Up to 180 days after index discharge

    Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge

Sponsors and collaborators

Lead sponsor

Singapore General Hospital

Other

Collaborators

  • Agency for Integrated Care, Singapore
  • Duke-NUS Graduate Medical School

Registry information

Important dates

Study start
2012
Primary completion
2014
Study completion
2014
First posted
Jan 30, 2015
Registry last updated
Jan 30, 2015

OpenTrials presents study information sourced from ClinicalTrials.gov. The official registry record should be consulted for the latest information.

View the official ClinicalTrials.gov record (opens in a new tab)

This listing is for discovery and informational purposes only. It is not medical advice, does not guarantee that a study is recruiting, and does not determine eligibility. Contact the study team and a qualified healthcare professional when considering participation.

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