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Completed

NCT Number: NCT02114515

PATient Navigator to rEduce Readmissions

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.

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Key information

Conditions

Chronic Obstructive Pulmonary Disease Anemia Anemia, Hemolytic Anemia, Hemolytic, Congenital Anemia, Sickle Cell Cardiovascular Diseases Chronic Disease Congenital, Hereditary, and Neonatal Diseases and Abnormalities Disease Attributes Genetic Diseases, Inborn Heart Diseases Heart Failure Hematologic Diseases Hemic and Lymphatic Diseases Hemoglobinopathies Infarction Infections Ischemia Lung Diseases Lung Diseases, Obstructive Myocardial Infarction Myocardial Ischemia Necrosis Pathologic Processes Pathological Conditions, Signs and Symptoms Pneumonia Pulmonary Disease, Chronic Obstructive Respiratory Tract Diseases Respiratory Tract Infections Sickle Cell Disease Vascular Diseases

Age range

18 year and older

Sex eligibility

All sexes

Study type

Interventional

Phase

Not applicable

Primary location

University of Illinois Hospital

Chicago, Illinois, 60612, United States

Who can participate

Healthy volunteers accepted: No

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

Inclusion criteria

  • Age 18 years or older on date of hospital admission
  • Hospitalized at the University of Illinois Hospital, Chicago
  • Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
  • Receive medical care on an inpatient medical service

Exclusion criteria

  • Unable to understand and speak English
  • Unable/decline to give informed consent
  • Previous participant in PArTNER
  • Planned transfer to another acute care facility
  • Planned discharge to facility other than home (e.g. long term care facility)
  • Currently on hospice or plans to discharge home to hospice
  • Current plans to leave against medical advice

Treatment and study plan

Hospital usual care

Behavioral

Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention

Behavioral

A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team

Peer-led telephone support line

Behavioral

The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Primary outcomes

  1. PROMIS Emotional Distress-Anxiety (v1.0, SF4a)

    Time frame: 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)

    Time frame: 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 outcomes

  1. PROMIS Emotional Support (v2.0, SF4a)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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)

    Time frame: 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

    Time frame: 30 days post discharge

    Caregiver-reported and confirmed by EHR review

  12. Death

    Time frame: 60 days post discharge

    Caregiver-reported and confirmed by EHR review

  13. Re-hospitalization or Death

    Time frame: 30 days post discharge

    Confirmed by EHR review

  14. Re-hospitalization or Death

    Time frame: 60 days post discharge

    Confirmed by EHR review

  15. ED Visit, Re-hospitalization, or Death

    Time frame: 30 days post discharge

    Confirmed by EHR review

  16. ED Visit, Re-hospitalization, or Death

    Time frame: 60 days post discharge

    Confirmed by EHR review

  17. Outpatient Healthcare Visit

    Time frame: 14 days post discharge

    Self-reported

  18. Outpatient Healthcare Visit

    Time frame: 14 days post discharge

    EHR-reported

Sponsors and collaborators

Lead sponsor

University of Illinois at Chicago

Other

Collaborators

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

Registry information

Acronym: PArTNER

Important dates

Study start
2014
Primary completion
2016
Study completion
2016
First posted
Apr 15, 2014
Registry last updated
Feb 15, 2019

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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