NCT04212962

Transitional Care Model Evaluation 2020

Evaluation of the Multisite Replication of the Transitional Care Model

• Status: Unknown
• Phase: N/A
• Study type: Interventional
• Enrollment: 962 (actual)
• Sponsor: Mathematica Policy Research, Inc. · Academic / Other
• Sex: All
• Age: 65 Years
• Healthy volunteers: Not accepted

Summary

The study is a randomized controlled trial to estimate the effects of the transitional care model (TCM) on hospital admissions and patients' experience during the year following the patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will be the coordinating center for the implementation. The study will be conducted in three large health systems spread throughout the U.S., drawing patients from seven hospitals in those systems. Eligible patients are older adults (age 65 and older) admitted to a participating hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia (PNA). The evaluation will be conducted by Mathematica.

Detailed description

The Transitional Care Model (TCM) is an advanced practice registered nurse (APRN) led, team-based, care management strategy designed to improve the care and outcomes of high-risk older adults transitioning from hospital to home. Eligible patients who agree to participate in the study will be randomly assigned to either the intervention group, which receives the TCM intervention, or the control group, which receives usual care (standard hospital discharge planning and post-hospital follow up services). The target sample size for the study is close to 1000, evenly divided into intervention and control groups, with 250 to 270 patients derived from each of UCSF and Trinity health systems, and another 450 recruited from the two VHA hospitals combined. Data will be collected at intake, prior to randomization, by enrollment coordinators at each of the participating hospitals. Followup data will be collected in a survey of patients conducted 90 days after discharge, and from claims data obtained from Medicare, Medicare Advantage plans, and the VHA.

Conditions

• CHF - Congestive Heart Failure
• COPD
• Pneumonia

Interventions

Type	Name	Description
BEHAVIORAL	Transitional care model (TCM)	Patient education about post-discharge self-care and medications, arrangement of needed social services, coordination of information from medical providers interacting with patient
BEHAVIORAL	Usual care	usual hospital discharge and post-discharge care

Timeline

• Start date: 2020-07-07
• Primary completion: 2024-07-01
• Completion: 2025-02-01
• First posted: 2019-12-30
• Last updated: 2023-03-16

Locations

1 site across 1 country: United States