Transition From Hospital to Home Post Cardiac Condition - Full Text View

Purpose

The study had three parts:

Part 1: Patients (or their home caretakers) who live outside of Denver and receive their primary care at a location other than the Denver VAMC were interviewed after their discharge. The interview covered the patient's perspective about the transition of their medical care from the Denver VA to their primary care facility.

Part 2: Primary care providers from the VA facilities that refer patients to the Denver VA were interviewed regarding their opinions of transition process from the Denver VA back to the primary care VA facilities.

Part 3: The data from the above interviews were used to develop an intervention to improve the transition process from the Denver VA back to the primary care VA facilities.

Condition	Intervention
Cardiac Condition	Behavioral: Intervention

Study Type:	Interventional
Study Design:	Allocation: Non-Randomized Intervention Model: Parallel Assignment Masking: Open Label Primary Purpose: Health Services Research
Official Title:	Pilot Intervention to Improve the Transition From Hospital to Home

Further study details as provided by Department of Veterans Affairs:

Primary Outcome Measures:

see primary outcome description below [ Time Frame: 2 years ] [ Designated as safety issue: No ]
Of Aim 1 pts, 3 of 8 (37.5%) went to a follow-up appt w/in 2 weeks of discharge. Of Aim 3 pts, 6 of 7 (85.7%) had a follow-up w/in 2 weeks of discharge. Medication reconciliation was done w/in 2 weeks in 50% of Aim 1 pts and 100% of Aim 3 pts. Discharge summaries weren't available in the remote data for any of Aim 1 pts and all Aim 3 pts had discharge summaries sent to their PCPs prior to the follow-up appt. Routine discharge instructions were given to all Aim 1 pts at discharge. Teach-back discharge instructions were given to Aim 3 pts at discharge and follow-up phone calls.

Enrollment:	34
Study Start Date:	August 2011
Study Completion Date:	December 2012
Primary Completion Date:	December 2012 (Final data collection date for primary outcome measure)

Arms	Assigned Interventions
No Intervention: Arm 1 Eight patients who were being discharged from Denver VA Medical Center for cardiac care to their primary care providers were recruited at the time of discharge and completed an interview two weeks following their discharge. Patients were asked to describe their transition to home and identify barriers and facilitators of this process, their understanding of their medical condition, new medications prescribed, timeliness of follow-up visit with their PCP and knowledge of signs/symptoms in which they should seek medical attention.
No Intervention: Arm 2 Three providers who refer patients to the Denver VA Medical Center for cardiac care were interviewed to identify barriers and facilitators from their perspective of following-up with patients after their hospitalization at Denver VAMC. Additionally, the same information was asked of providers who participated in two focus groups in the Grand Junction VA.
Experimental: Arm 3 Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention	Behavioral: Intervention Informed by the interviews and best practices from the literature, pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention

Detailed Description:

Aim 1 was to describe barriers and facilitators of the transition process from hospital to home through qualitative interviews among patients discharged from Denver VA Medical Center (tertiary facility) after being transferred from a primary care VA.

Aim 2 was to describe barriers and facilitators of the transition process through qualitative interviews among providers at primary care VA facilities who take care of patients discharged from the Denver VA Medical Center for a cardiac condition.

Aim 3 was to pilot test the transitions of care intervention that targets patients and providers to evaluate the feasibility of the intervention to improve process of care measures, including: 1) PCP follow-up within 2-4 weeks of hospital discharge; 2) medications reconciled between pre and post-hospital discharge; 3) discharge summary available to PCP at time of visit; and 4) patient awareness of symptoms that require medical attention. This pilot was informed by the interviews from Aims 1 and 2 and best practices from the literature. Finally, as part of Aim 3, the primary care providers who saw the patients who completed the pilot were contacted to ask for their input and feedback regarding the pilot project.

Description of Enrolled Population: Study Design and Research Methods This was a mixed methods study where both qualitative and quantitative methods were employed. Through a series of qualitative interviews (n=26), potential barriers and facilitators of the current discharge process were assessed in this hub and spoke model of cardiac care. Informed by these interviews, the transitions of care intervention refined elements from prior studies that have improved this transition process. Finally, a pilot test of this intervention was implemented to assess the effectiveness of the intervention to improve important processes of care during this transition period among patients (n=8) discharged from Denver VAMC after transfer from a primary care VA facility.

Eligibility

Ages Eligible for Study:	18 Years to 90 Years
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	Yes

Criteria

Inclusion Criteria:

Aims 1 and 3:

Patients transferred from primary care VA facilities (i.e., Cheyenne, Grand Junction, Sheridan, Ft. Harrison) for cardiac care (e.g., heart failure, acute myocardial infarction) or procedures (coronary angiography, pacemaker implantation) to the Denver VAMC and discharged home to follow-up with their primary care provider, were eligible.

Aim 2:

Providers from VA primary care facilities, (i.e., Cheyenne, Grand Junction, Sheridan, and Ft. Harrison) who took care of patients discharged from the Denver VAMC for cardiology care, were eligible for the qualitative interviews.

Exclusion Criteria:

Aims 1 and 3:

Exclusion criteria included:
- Planned discharge to nursing home or skilled nursing facility;
- Irreversible, non-cardiac medical condition (e.g. metastatic cancer) likely to affect 6-month survival or ability to execute study protocol;
- Lack of telephone/ cell phone; and
- VA is not their primary source of care or their PCP is not in the VA system.

Aim 2: There were exclusion criteria.

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT01431846

Locations

United States, Colorado
VA Eastern Colorado Health Care System, Denver
Denver, Colorado, United States, 80220

Sponsors and Collaborators

Department of Veterans Affairs

Investigators

Principal Investigator:

Michael Ho, MD PhD

VA Eastern Colorado Health Care System, Denver

More Information

No publications provided

Responsible Party:	Department of Veterans Affairs
ClinicalTrials.gov Identifier:	NCT01431846 History of Changes
Other Study ID Numbers:	RRP 11-242
Study First Received:	June 23, 2011
Last Updated:	April 18, 2013
Health Authority:	United States: Federal Government

ClinicalTrials.gov processed this record on May 16, 2013