Epilepsy Emergency Department High Utilizer Program

We believe that there are many reasons that people with epilepsy get their health care through the emergency department (ED) instead of through primary care or neurology. Our goal is to create program that will address these reasons. The creation of this program will be informed by use of the Grady electronic health records (EHR). We will use the EHR to describe people with epilepsy coming the Grady ED at a high frequency. We create a profile of these patients by examining their demographics and social determinants of health information in their EHR (Aim 1). We will then use that information to create a culturally and medically appropriate program for people with epilepsy (Aim 2). Next, we will test the new program, the Epilepsy Emergency Department High Utilizer Program (Aim 3). We believe this program may improve three things. It will first improve access to care by epilepsy and mental health doctors, and reduce ED visits. It may also help people to manage their triggers, track seizures, and take their medicines on time. And last, we believe it may improve seizure frequency and quality of life for people that are underserved in health care. With the lessons learned from the new program, we will explore ways to sustain the program at Grady and expand it to other health care facilities (Aim 4).

Enrolling by Invitation

Interested in participating?

Request Info

Key information

Conditions

Epilepsy Brain Diseases Central Nervous System Diseases Nervous System Diseases Uncontrolled Seizures

Age range

18 year and older

Sex eligibility

Female

Study type

Observational

Primary location

Morehouse School of Medicine

Atlanta, Georgia, 30310, United States

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

Adult women aged 18 years or older
Confirmed diagnosis of epilepsy documented in the electronic health record (EHR)
Enrolled in the Grady Health System Transition of Care (TOC) ED High Utilizer Program
History of three or more seizure-related emergency department visits within the past 12 months
Self-identify as Black or Hispanic
Reside in the Atlanta metropolitan area with intent to remain for at least 12 months
Have access to a working phone for follow-up communication

Exclusion criteria

No confirmed epilepsy diagnosis (e.g., non-epileptic seizures)
Younger than 18 years of age
Not identified as a high ED utilizer for seizure-related care
Unable to provide informed consent due to cognitive impairment or psychiatric instability
Regularly taking anti-epileptic medications with established adherence
Scheduled neurology follow-up within 14 days of discharge or consistent primary care follow-up
Complex medical conditions that would limit participation in outpatient follow-up
Non-English speaking
Pregnant

Treatment and study plan

CHW-Led Transition-of-Care Intervention

Behavioral

Participants receive a community health worker (CHW)-led transition-of-care intervention for adults with epilepsy who frequently use emergency department services. Over 9-12 months, the CHW provides home visits and phone follow-up to support seizure self-management, medication adherence, and care coordination.

The CHW assists with appointment scheduling, connects participants to healthcare and community resources, and addresses social needs such as transportation and access to care. The goal is to improve continuity of care and reduce emergency department utilization.

Primary outcomes

Emergency Department Utilization

Time frame: Baseline to 9-12 months post-enrollment

Reduced emergency department visits

Sponsors and collaborators

Lead sponsor

Morehouse School of Medicine

Other

Collaborators

Emory University
Epilepsy Foundation
Grady Health System
NYU Langone Health
UCB Pharma

Registry information

Important dates

Study start: 2026
Primary completion: 2026
Study completion: 2026
First posted: Jun 23, 2026
Registry last updated: Jun 23, 2026

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.

Published trials that share one or more normalized conditions with this study.

Enrolling by Invitation