NCT01916876

Impact of Medical Follow-up Discharge Package

A Randomised Controlled Trial of an Integrated Post-discharge Transitional Care Package for General Medical In-patients in Cape Town, South Africa

• Status: Withdrawn
• Phase: N/A
• Study type: Interventional
• Enrollment: 0 (actual)
• Sponsor: University of Cape Town · Academic / Other
• Sex: All
• Age: 18 Years
• Healthy volunteers: Not accepted

Summary

The post discharge time is a vulnerable time for general medical in-patients, with high rates of adverse events that may cause unnecessary readmissions and even death. A recent study of 415 patients discharged from the general medical wards at Groote Schuur Hospital, demonstrated a very high 12 month mortality of 35%. The majority of these deaths were classified as "unexpected". The reasons for this were not further examined, but it was speculated, given the authors' knowledge of the public sector in Cape Town, that three related factors contribute significantly to this early mortality: i) a lack of continuity of care, with patients not necessarily accessing the primary care support treatment that they need or being able to access early post discharge follow-up (for example for anti-retroviral or anti-tuberculous care); ii) the inability of primary care to deal with the complex nature of the discharged patients, most whom have significant co-morbid disease; iii) A lack of optimisation of therapy for chronic disease after acute discharge. The investigators hypothesise that an integrated post-discharge transitional care package, which includes an early medical specialist follow-up in the first 3 months after hospital discharge will decrease the 6- and 12-month mortality and re-admission rate amongst general medical hospital admissions in Cape Town, South Africa. Our study will compare an integrated package, suitable to implementation if effective, with current standard discharge packages.

Conditions

• Follow-up Study
• Medical In-patients

Interventions

Type	Name	Description
OTHER	Integrated medical follow-up package	At discharge, patients will receive a discharge plan by their attending caregiver. 1. On day 3 they will be contacted telephonically to: i) Discuss their discharge diagnosis and medications ii) Arrange specialist clinic follow-up booking for 2 weeks iii) Reemphasise drug compliance 2. Reminders via SMS to attend there OPD appointment(s) 3. Medical out-patient review at 2-weeks and 6 weeks if required 4. Medical telephonic "hot-line" for advice

Timeline

• Start date: 2015-03-01
• Primary completion: 2015-12-01
• Completion: 2016-05-01
• First posted: 2013-08-06
• Last updated: 2014-12-03

Locations

2 sites across 1 country: South Africa