New or worsening symptoms following discharge from the hospital likely leads to unplanned readmission. These rates are higher than desired and costly to patients, payers, and providers. Many interventions have unsuccessfully attempted to reduce readmissions, but few have provided in-home personnel to patients transitioning from acute care back to ambulatory care. Still fewer have involved a physician in the home. We therefore will test the effect of a physician home visit to a patient's home who was discharged in the last 4 days.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
51
The visit will be entirely patient tailored, last approximately one hour, and at a minimum will entail: * Medical assessment * Psychosocial assessment * Medication reconciliation * Follow-up of inpatient primary team's specific recommendations * Follow-up, as needed, with primary care team or inpatient team
Brigham and Women's Hospital
Boston, Massachusetts, United States
Brigham and Women's Faulkner Hospital
Boston, Massachusetts, United States
New or worsening symptoms
"Since you got home from the hospital, have you had any symptoms at all?" If no, stop. If yes, continue. "I'm going to read off a list of symptoms, and I want you to tell me if that symptom is new or has gotten worse since you left the hospital. Please don't include symptoms that have stayed the same since you were in the hospital." For each affirmative, double check if the symptom is new or has gotten worse since getting out of the hospital. Only if new or worse, mark yes.
Time frame: 30 days after discharge from hospital
Total cost, 30-days post discharge
Time frame: Day of discharge to 30 days later
Total reimbursement, 30-days post discharge
Time frame: Day of discharge to 30 days later
3-item Care Transition Measure, score
Time frame: 30 days after discharge
Primary care provider follow-up within 14 days, y/n
Time frame: Day of discharge to 14 days later
Ability to carry out the discharge plan, score
I would like to ask you about some more problems that you might have faced after you left the hospital one month ago. I will read some statements and ask if you agree or disagree.
Time frame: 30 days after discharge
Change in medication list due to home visit, y/n
Physician-initiated medication change during home visit
Time frame: Day of home visit
Receipt of prescribed medicines following discharge, y/n
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Pharmacy confirmation
Time frame: 30 days after discharge
Unplanned 30-day readmission(s) after index hospitalization, y/n
Time frame: 30 days after discharge
Unplanned 30-day readmission(s) after index hospitalization, #
Time frame: 30 days after discharge