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A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

Primary Purpose

Chronic Diseases

Status
Completed
Phase
Not Applicable
Locations
Singapore
Study Type
Interventional
Intervention
a transitional care model
Control
Sponsored by
Singapore General Hospital
About
Eligibility
Locations
Arms
Outcomes
Full info

About this trial

This is an interventional health services research trial for Chronic Diseases focused on measuring readmission, care transition

Eligibility Criteria

21 Years - undefined (Adult, Older Adult)All SexesDoes not accept healthy volunteers

Inclusion criteria

-More than 1 admission in the last 90 days

Exclusion Criteria

  • Subject is a non-resident
  • Subject has no local home address
  • Subject is from a long-term care facility during index admission
  • Subject is unable to participate in telephone surveillance
  • Subject is discharged before takeover
  • Subject has impaired decision making capacity without surrogate decision maker
  • Subject is pending or currently in critical care unit
  • Subject or caregiver is mentally unstable
  • Subject is haemodynamically unstable
  • Subject requires acute inpatient respiratory support
  • Subject requires acute inpatient dialysis support
  • Subject pending surgical intervention
  • Subject pending transfer to other specialist discipline
  • Primary team consultant declined to participate in this research

Sites / Locations

  • Singapore General Hospital

Arms of the Study

Arm 1

Arm 2

Arm Type

Experimental

Active Comparator

Arm Label

Intervention'

Control'

Arm Description

Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients

Patients receive usual standard of care from the internal medicine team

Outcomes

Primary Outcome Measures

Readmission rate
A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients

Secondary Outcome Measures

Readmission rate
Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge
Quality of transitional care using a validated care transition measure (CTM-15) tool
Care transition measure survey of subjects
Emergency department attendance rate
Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge
Time to first readmission
Censored time to readmission for both intervention and control group
Specialist Outpatient Clinic visits
Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge

Full Information

First Posted
January 21, 2015
Last Updated
January 29, 2015
Sponsor
Singapore General Hospital
Collaborators
Agency for Integrated Care, Singapore, Duke-NUS Graduate Medical School
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1. Study Identification

Unique Protocol Identification Number
NCT02351648
Brief Title
A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
Official Title
A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital
Study Type
Interventional

2. Study Status

Record Verification Date
January 2015
Overall Recruitment Status
Completed
Study Start Date
October 2012 (undefined)
Primary Completion Date
December 2014 (Actual)
Study Completion Date
December 2014 (Actual)

3. Sponsor/Collaborators

Responsible Party, by Official Title
Sponsor
Name of the Sponsor
Singapore General Hospital
Collaborators
Agency for Integrated Care, Singapore, Duke-NUS Graduate Medical School

4. Oversight

Data Monitoring Committee
No

5. Study Description

Brief Summary
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH
Detailed Description
Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending Primary Aim: To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Secondary Aim: To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)

6. Conditions and Keywords

Primary Disease or Condition Being Studied in the Trial, or the Focus of the Study
Chronic Diseases
Keywords
readmission, care transition

7. Study Design

Primary Purpose
Health Services Research
Study Phase
Not Applicable
Interventional Study Model
Parallel Assignment
Masking
Outcomes Assessor
Allocation
Randomized
Enrollment
840 (Actual)

8. Arms, Groups, and Interventions

Arm Title
Intervention'
Arm Type
Experimental
Arm Description
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
Arm Title
Control'
Arm Type
Active Comparator
Arm Description
Patients receive usual standard of care from the internal medicine team
Intervention Type
Other
Intervention Name(s)
a transitional care model
Intervention Description
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
Intervention Type
Other
Intervention Name(s)
Control
Intervention Description
Patients receive usual standard of care from the internal medicine team
Primary Outcome Measure Information:
Title
Readmission rate
Description
A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients
Time Frame
30 days after index discharge
Secondary Outcome Measure Information:
Title
Readmission rate
Description
Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge
Time Frame
up to 180 days after index discharge
Title
Quality of transitional care using a validated care transition measure (CTM-15) tool
Description
Care transition measure survey of subjects
Time Frame
90 days after index discharge
Title
Emergency department attendance rate
Description
Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge
Time Frame
Up to 180 days after index discharge
Title
Time to first readmission
Description
Censored time to readmission for both intervention and control group
Time Frame
Up to 90 days after index discharge
Title
Specialist Outpatient Clinic visits
Description
Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge
Time Frame
Up to 180 days after index discharge

10. Eligibility

Sex
All
Minimum Age & Unit of Time
21 Years
Accepts Healthy Volunteers
No
Eligibility Criteria
Inclusion criteria -More than 1 admission in the last 90 days Exclusion Criteria Subject is a non-resident Subject has no local home address Subject is from a long-term care facility during index admission Subject is unable to participate in telephone surveillance Subject is discharged before takeover Subject has impaired decision making capacity without surrogate decision maker Subject is pending or currently in critical care unit Subject or caregiver is mentally unstable Subject is haemodynamically unstable Subject requires acute inpatient respiratory support Subject requires acute inpatient dialysis support Subject pending surgical intervention Subject pending transfer to other specialist discipline Primary team consultant declined to participate in this research
Overall Study Officials:
First Name & Middle Initial & Last Name & Degree
Kheng Hock Lee, MBBS
Organizational Affiliation
Singapore General Hospital
Official's Role
Principal Investigator
Facility Information:
Facility Name
Singapore General Hospital
City
Singapore
ZIP/Postal Code
169608
Country
Singapore

12. IPD Sharing Statement

Citations:
PubMed Identifier
16896392
Citation
Coleman EA, Smith JD, Frank JC, Eilertsen TB, Thiare JN, Kramer AM. Development and testing of a measure designed to assess the quality of care transitions. Int J Integr Care. 2002;2:e02. doi: 10.5334/ijic.60. Epub 2002 Jun 1.
Results Reference
background
PubMed Identifier
12558354
Citation
Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003 Feb 4;138(3):161-7. doi: 10.7326/0003-4819-138-3-200302040-00007.
Results Reference
result
PubMed Identifier
17054207
Citation
Mistiaen P, Poot E. Telephone follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged from hospital to home. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD004510. doi: 10.1002/14651858.CD004510.pub3.
Results Reference
result

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A Randomised Control Trial of a Transitional Care Model in Singapore General Hospital

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