Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE
Enrollment
1,029
Written discharge instructions provided to patients prior to hospital discharge.
A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team
The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
University of Illinois Hospital
Chicago, Illinois, United States
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates improvement. A change equal to 0 indicates no change. A change \>0 indicates worsening.
Time frame: 30 days post discharge
PROMIS Informational Support (v2.0, SF4a)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 30 days post discharge
PROMIS Emotional Support (v2.0, SF4a)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 30 days post discharge
PROMIS Instrumental Support (v2.0, SF4a)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 30 days post discharge
PROMIS Global Health, Physical (v1.1, SF)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 30 days post discharge
PROMIS Global Health, Mental (v1.1, SF)
Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 30 days post discharge
PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates improvement. A change equal to 0 indicates no change. A change \>0 indicates worsening.
Time frame: 60 days post discharge
PROMIS Informational Support (v2.0, SF4a)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 60 days post discharge
PROMIS Emotional Support (v2.0, SF4a)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 60 days post discharge
PROMIS Instrumental Support (v2.0, SF4a)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 60 days post discharge
PROMIS Global Health, Physical (v1.1, SF)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 60 days post discharge
PROMIS Global Health, Mental (v1.1, SF)
Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.
Time frame: 60 days post discharge
Death
Caregiver-reported and confirmed by EHR review
Time frame: 30 days post discharge
Death
Caregiver-reported and confirmed by EHR review
Time frame: 60 days post discharge
Re-hospitalization or Death
Confirmed by EHR review
Time frame: 30 days post discharge
Re-hospitalization or Death
Confirmed by EHR review
Time frame: 60 days post discharge
ED Visit, Re-hospitalization, or Death
Confirmed by EHR review
Time frame: 30 days post discharge
ED Visit, Re-hospitalization, or Death
Confirmed by EHR review
Time frame: 60 days post discharge
Outpatient Healthcare Visit
Self-reported
Time frame: 14 days post discharge
Outpatient Healthcare Visit
EHR-reported
Time frame: 14 days post discharge
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.