A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

A Prospective Randomised Control Trial to Study the Effectiveness of a Health Service Innovation Using a Modified Virtual Ward Model to Prevent Unscheduled Readmission of High Risk Patients

The investigators conducted an open randomized control study of patients who received the transitional care program versus patients who received usual care at the Singapore General Hospital from Aug 2011 to Sept 2012.

The investigators conducted an open randomized control study of patients who received the transitional care program versus patients who received usual care at the Singapore General Hospital from Aug 2011 to Sept 2012.

Patients in the control group received usual care by the hospital. There was no contact between the patients in the control group and the study team throughout the 3 months interval. A scheduled telephone call was made at the end of 3 months when they were invited to participate in a telephone survey.

A multidisciplinary team delivered the transitional care program. Our transitional care program focused on four key areas: Post discharge surveillance of the patient to ensure adherence to care plans. Coordination of follow-up visits with specialist care providers. Patent education and care giver training. Activation of community and social services. Upon recruitment, the patients were interviewed and assessed by the team nurse prior to their discharge. Intervention starts upon discharge from the hospital. The duration of the intervention program was 3 months. A follow-up by telephone was made within 72 hours after discharge to assess patient's condition and adherence to treatment plan. Home visits were made within 2 weeks after discharge.

Inclusion Criteria: Patients with 2 or more unscheduled admission in the last 90 days to selected medical departments LACE score of ≥10. Exclusion Criteria: Non-residents No telephone contact or a resident address Residing in long term care facilities.

Lee KH, Low LL, Allen J, Barbier S, Ng LB, Ng MJ, Tay WY, Tan SY. Transitional care for the highest risk patients: findings of a randomised control study. Int J Integr Care. 2015 Oct 22;15:e039. doi: 10.5334/ijic.2003. eCollection 2015 Oct-Dec.