An Emergency Department-To-Home Intervention to Improve Quality of Life and Reduce Hospital Use
| Status: | Completed |
|---|---|
| Conditions: | Hospital |
| Therapuetic Areas: | Other |
| Healthy: | No |
| Age Range: | 60 - Any |
| Updated: | 4/6/2019 |
| Start Date: | May 3, 2014 |
| End Date: | March 10, 2017 |
The purpose of this study is to determine if assigning older, chronically ill patients a
healthcare coach after they leave the Emergency Department (ED) improves their quality of
life and reduces the need for hospital-based care.
healthcare coach after they leave the Emergency Department (ED) improves their quality of
life and reduces the need for hospital-based care.
Investigators will review the ED electronic medical record in real-time to determine ED
patients' study eligibility. Older, chronically ill ED patients who are eligible and agree to
participate in the study will be randomly assigned to a healthcare coach and Care Transition
Intervention or usual, post-ED care.
At the time of enrollment, all subjects will be asked to provide informed consent for study
investigators to request Medicare Claims to determine how many ED visits, hospital admissions
and doctor office visits the subject had at least 30 days after the index ED visit. All
research participants will be asked basic personal information such as age, race, sex,
employment and marital status. All subjects will be asked to complete a baseline survey about
their quality of life.
If the subject is assigned to the Care Transition Intervention, the healthcare coach will
visit the subject at home within 3 days of the ED visit. The coach will talk with the subject
about following up with a regular, personal doctor and symptoms that indicate a worsening
health condition. The coach will help the subject understand their medicines and help the
subject make a personal health record (PHR). The coach will tell the subject about the Area
Agency on Aging. If the subject receives usual care, they but will be given the usual
discharge instructions from the ED nurse and doctor. If the subject receives the Care
Transition Intervention, the coach will also call the subject at least 3 times after the ED
visit and review the same items listed above.
All enrolled subjects will be asked to complete a phone survey within 31-60 days of the ED
visit. This survey will again ask subjects about their quality of life.
patients' study eligibility. Older, chronically ill ED patients who are eligible and agree to
participate in the study will be randomly assigned to a healthcare coach and Care Transition
Intervention or usual, post-ED care.
At the time of enrollment, all subjects will be asked to provide informed consent for study
investigators to request Medicare Claims to determine how many ED visits, hospital admissions
and doctor office visits the subject had at least 30 days after the index ED visit. All
research participants will be asked basic personal information such as age, race, sex,
employment and marital status. All subjects will be asked to complete a baseline survey about
their quality of life.
If the subject is assigned to the Care Transition Intervention, the healthcare coach will
visit the subject at home within 3 days of the ED visit. The coach will talk with the subject
about following up with a regular, personal doctor and symptoms that indicate a worsening
health condition. The coach will help the subject understand their medicines and help the
subject make a personal health record (PHR). The coach will tell the subject about the Area
Agency on Aging. If the subject receives usual care, they but will be given the usual
discharge instructions from the ED nurse and doctor. If the subject receives the Care
Transition Intervention, the coach will also call the subject at least 3 times after the ED
visit and review the same items listed above.
All enrolled subjects will be asked to complete a phone survey within 31-60 days of the ED
visit. This survey will again ask subjects about their quality of life.
Inclusion Criteria:
- 60 years of age or older
- Medicare beneficiaries
- Community dwelling
- Reside within defined geographical area (to enable home visits)
- Have a working telephone
- Have at least one of the following conditions documented in their electronic medical
record: congestive heart failure, chronic obstructive pulmonary disease, coronary
artery disease, diabetes, stroke, pneumonia, medical and surgical back conditions
(predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac
arrhythmias, deep venous thrombosis, pulmonary embolism, peptic ulcer disease or
hemorrhage
Exclusion Criteria:
- Current diagnosis of psychosis
- Cancer
- Dialysis
- History of organ transplantation
- Dementia without a live-in caregiver, or
- In hospice care
- Reside outside the defined geographical area
- Reside in a skilled nursing or assisted living facility
We found this trial at
2
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