There is overwhelming evidence that patients with multiple chronic illnesses need better self-management skills. Discharge from the hospital may not be the most opportune time to be teaching patients these self-management skills. There are several different care transition models being used across the country; however we know that not every patient needs the same type or amount of an intervention. The purpose of this pilot study is to study the impact delivering a home based care transitions intervention (HBCTI) with four different groups tailored on cognition and level of patient activation compared to usual care (UC) resulting in 8 study arms on the outcomes of health care utilization (HCU) and health outcomes: patient-reported health status, assessment of care for chronic conditions, and health related quality of life in adult patients with multiple chronic diseases dismissed to home from an acute care facility. Our working hypothesis is that patients in the HBCTI groups compared to the UC groups will have lower HCU and improved outcomes (patient-reported health status, assessment of care for chronic conditions, and health related quality of life).
One in five Medicare patients discharged from the hospital experience readmission within 30 days. Too often, hospital readmissions result from inadequate transition from hospital to home at discharge. Care transitions are complicated because of high patient acuity, multiple comorbidities, decreased length of stay, and multiple clinician involvement increasing the number of handoffs. With decreased length of stay, many patients do not comprehend or feel confident with instructions for discharge, thus management of their chronic illnesses are difficult. Most formal care transition programs are standardized and every patient receives similar strategies or interventions. However, it has been well documented that patients with cognitive problems and decreased activation are at high risk for re-hospitalization related to impaired self-management. We believe that assessment of cognition and patient activation during the patient's hospitalization will provide valuable information for discharge interventions. Data related to cognition and activation can be used to tailor discharge planning and help determine what type and how many resources are needed for individual patients after hospital discharge. The purpose of this feasibility study is to examine the impact of delivering a home based care transitions interventions (HBCTIs) with four different groups tailored on cognition and level of patient activation compared to usual care (UC) on the outcomes of health care utilization (HCU) and health outcomes: patient-reported health status, assessment of care for chronic conditions, and health related quality of life in adult patients with multiple chronic diseases discharged to home from the hospital. We will test our intervention with the following aims: Aim 1.To evaluate the impact of HBCTIs on health care utilization. We will measure HCU (number of emergency department(ED) visits and number of readmissions) at 6 months after discharge. Our working hypothesis is that patients in the HBCTI groups compared to the UC groups will have lower HCU over time (6 months); Aim 2. To evaluate the impact of HBCTIs on the following health outcomes: patient-reported health status (PROMIS-29), assessment of care for chronic conditions (PACIC), and quality of life (EuroQol). Our working hypothesis is that patients in the HBCTI groups compared to the UC group will have improved patient-reported health status, assessment of care for chronic conditions, and quality of life (EuroQol) at 6 months after discharge. The findings from this study have the potential to change this paradigm in three ways: 1) we will gain a better understanding of the role of cognition and patient activation in promoting self-management to enhance outcomes; 2). our innovative approach, which considers the unique needs of patients based on their level of cognition and patient activation will advance new concepts in care transition programs; 3) we will have a better understanding of varying intensities of visits, level of providers, and type and amount of strategies administered. This practical model for care transitions could serve as a model within the larger health care delivery system that could result in significant cost savings.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
263
The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider. Education is provided at a 5th grade reading level. The "teach back" method is used to validate knowledge, skills and confidence. Once knowledge is validated, the interventions focused on motivation.
The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider. Education is provided at a 5th grade reading level. The "teach back" method is used to validate knowledge, skills and confidence. Once knowledge is validated, the interventions focused on motivation and handling stressful situations.
The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider. Education is provided for areas of misunderstanding. The "teach back" method is used to validate knowledge, skills and confidence. Interventions are focused on motivation and developing personal behavioral goals.
The intervention is focused on knowledge, skills, confidence and creating a partnership with the health care provider. Focus is on maintaining behaviors during hardship and stress. Empowering, motivating and validating are strategies utilized.
Saint Elizabeth Regional Medical Center
Lincoln, Nebraska, United States
Health Care Utilization
Patient report of number of Emergency Department Visits and number of re-admissions to the hospital within a 6 month time period was measured. Validation data was obtained from the clinical sites.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System - Pain Interference
Pain interference is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Assessing patient perception of pain interference is measured as a 4-item short form scale on the PROMIS-29 survey. Each item is scored from 1-5 with a 1 indicating "not at all" and 5 indicating "very much." The T-Score for the average general population is 50. Higher scores mean more pain interference, thus a worse outcome. A score change of 2-3 points has been reported as clinically meaningful differences.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System-Physical Functioning
Physical Functioning is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Physical functioning is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the Physical Functioning items are scored from 1-5, with a 1 indicating "unable to do" and 5 indicating "without any difficulty." Each subscales forms its own score subscale measures are scored on the T-score metric. High scores indicating better or higher physical functioning
Time frame: 6 months after intervention
Patient-Reported Outcomes Measurement Information System-Satisfaction With Social Roles
Ability to participate in social roles and activities is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Ability to participate in social roles and activities is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the PROMIS-29 are scored from 1-5, with a 1 indicating "never" and 5 indicating "always." Each subscales forms its own score subscale measures are scored on the T-score metric. High scores indicating more ability to participate in social roles and activities.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System- Anxiety
Anxiety is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Assessing patient anxiety is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the PROMIS-29 are scored from 1-5, with a 1 indicating "never" and 5 indicating "always." Each subscales forms its own score subscale measures are scored on the T-score metric. High scores indicating more anxiety and a worse outcome, and lower scores are indicative of less anxiety and a better outcome.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System-Fatigue
Fatigue is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Fatigue is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the PROMIS-29 are scored from 1-5, with a 1 indicating "not at all" and 5 indicating "very much." Each subscales forms its own score subscale measures are scored on the T-score metric. High scores indicating more fatigue and a worse outcome and lower scores are indicative of less fatigue and a better outcome.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System- Depression
Depression is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Depression is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the PROMIS-29 are scored from 1-5, with a 1 indicating "never" and 5 indicating "always." Each subscales forms its own score subscale measures are scored on the T-score metric. High scores indicating more feeling of depression and a worse outcome and lower scores are indicative of less depression and a better outcome.
Time frame: 6 months
Patient-Reported Outcomes Measurement Information System-Sleep Deprivation
Sleep disturbance is one of the 7 domains of the Patient Reported Outcomes Measurement Information System (PROMIS). The PROMIS-29 is the shortest profile, with 4 questions asked for each of 7 domains, plus the single pain intensity item. PROMIS measures are scored on the T-score metric. Each short form is scored separately, yielding a total of 7 domain scores. The T-score rescales the raw score into a standardized score with a mean of 50 and a standard deviation (SD) of 10. There is no total score, but each axis forms its own score. Assessing sleep disturbance is measured as a 4-item short form subscale on the PROMIS-29 survey. The patients' answers to the sleep disturbance domain are scored from 1-5, with a 1 indicating "very good or very much" and 5 indicating "very poor or not at all." High scores indicating more sleep disturbance and a worse outcome, and lower scores are indicative of less sleep disturbance and a better outcome.
Time frame: 6 months
Patient Assessment of Chronic Illness Care
The Patient Assessment of Chronic Illness Care (PACIC) Survey is a 20-item patient report instrument that assesses patient's receipt of clinical services and actions consistent with the Chronic Care Model. Respondents rate how often they experienced the content described in the item on a 5-point scale ranging from 1 (no or never) to 5 (yes or always). Patients rated the care received from their health care team. The PACIC consists of 5 scales and an overall summary score, each having good internal consistency for brief scales. The five subscales were Patient Activation; Delivery System/ Decision Support; Goal Setting; Problem-solving/Contextual Counseling; and Follow-up/ Coordination. Overall mean summary score (range 1-5) was used in analysis. Higher scores are more positive rating of their receipt of clinical services.
Time frame: 6 months
Health Related Quality of Life EuroQol-5D (EQ-5D)
Quality of life was measured by the EuroQol-5 (EQ-5D) and consists of 1 question for each of the 5 dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension has 5 levels: no problems, slight problems, moderate problems, severe problems and extreme problems. Patients indicate their health state for each of the 5 dimensions. The 5 responses give a health state represented by a 5-digit number (for example, 12231) corresponding to response categories reported by patients for the dimensions. Health states are scored to give the EQ-5D-5L index using a scoring algorithm from a value set derived from valuation tasks typically undertaken with general population samples. The five dimensions are combined into a 5-digit number that describes the patient's health state. EQ-5D-5L index scores range from -0.59 to 1, where 1 is the best possible health state. Negative values represent health states perceived as worse than dead, which is equal to 0.
Time frame: 6 months
EQ-5D Visual Analog Scale (VAS)
Used alongside the EuroQol-5D (EQ-5D), the EQ visual analog scale (VAS) is a 20 cm VAS "assessing your own health today" with endpoints labeled "Best imaginable health state" (100) and "Worst imaginable health state" (0). EQ VAS scores range from 0 to 100, where 100 is the best possible health state.
Time frame: 6 months
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