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NCT Number: NCT02421133

Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward

In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.

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Key information

Conditions

Geriatrics

Age range

75 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

CH Gériatrique des Monts d'Or, Albigny-sur-Saône, France

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About this study

The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

  • Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
  • Aged 75 or older.
  • Leaving at home and with home as the planned discharge after the admission.
  • At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).

Exclusion criteria

  • Patient leaving in a retirement home.
  • Patient hospitalized at home.
  • Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission

Treatment and study plan

Transitional care program.

Other

During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge.

The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring.

During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.

Standard care program

Other

The patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work.

Primary outcomes

  1. 30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.

    Time frame: Within 30 days after hospital discharge.

    Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).

Secondary outcomes

  1. Length of stay in the short stay geriatric ward (index hospitalization)

    Time frame: Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days

  2. Unscheduled hospital readmissions or emergency room visits

    Time frame: Within 30 and 90 days after the index hospital discharge.

  3. Free-hospitalization survival

    Time frame: Within 30 and 90 days after the index hospital discharge.

  4. Mortality rate

    Time frame: Within 30 and 90 days after the index hospital discharge.

  5. Adverse events (i.e. falls)

    Time frame: Within 30 days after the index hospital discharge.

  6. Quality of life.

    Time frame: Within 30 days after the index hospital discharge.

    Measured with the French version of the EUROQOL-5D.

  7. Patients' satisfaction care transition programme

    Time frame: Within 30 days after the index hospital discharge.

    Measured with the Care Transition Measure® questionnaire.

  8. Delay between the index hospital discharge and the implementation of home care.

    Time frame: Within 30 days after the index hospital discharge.

  9. Number of contacts between the transition nurse and the primary care providers or the hospital providers after discharge

    Time frame: Within 30 days after the index hospital discharge.

  10. Costs of unscheduled hospital readmission or emergency visit

    Time frame: 30 days after discharge

    Hospital and community care costs after discharge

Sponsors and collaborators

Lead sponsor

Hospices Civils de Lyon

Other

Registry information

Official study title

Impact of a Transitional Care Program Involving an Advanced Practice Nurse on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward (PROUST Study)

Acronym: PROUST

Important dates

Study start
2015
Primary completion
2016
Study completion
2016
First posted
Apr 20, 2015
Registry last updated
Dec 19, 2025

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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