NCT02351648

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

• Status: Completed
• Phase: N/A
• Study type: Interventional
• Enrollment: 840 (actual)
• Sponsor: Singapore General Hospital · Academic / Other
• Sex: All
• Age: 21 Years
• Healthy volunteers: Not accepted

Summary

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

Detailed description

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)

Conditions

• Chronic Diseases

Interventions

Type	Name	Description
OTHER	a transitional care model	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
OTHER	Control	Patients receive usual standard of care from the internal medicine team

Timeline

• Start date: 2012-10-01
• Primary completion: 2014-12-01
• Completion: 2014-12-01
• First posted: 2015-01-30
• Last updated: 2015-01-30

Locations

1 site across 1 country: Singapore