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The Impact of Post Discharge One-Time Home Visit: Bridging the Gap Between Hospital and Home.

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT00276367
Recruitment Status : Withdrawn (is involved in NIH study)
First Posted : January 13, 2006
Last Update Posted : May 13, 2015
Information provided by:
Maimonides Medical Center

Brief Summary:
A single post-hospital discharge home visit by a geriatric nurse practitioner or geriatric fellow can bridge the gap and ease the transition for elderly frail patients returning home after hospital admission. We believe this intervention will reduce medication errors, ensure follow-up discharge plans, decrease re-hospitalization rates, and decrease morbidity and mortality.

Condition or disease
COPD Coronary Artery Disease Diabetes Mellitus Stroke

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Study Type : Observational
Actual Enrollment : 0 participants
Study Start Date : October 2006

Information from the National Library of Medicine

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Ages Eligible for Study:   65 Years and older   (Older Adult)
Sexes Eligible for Study:   All
Sampling Method:   Non-Probability Sample
Study Population
Although IRB approval was received, study was not initiated.

Inclusion Criteria:

Patients admitted to the ACE unit during the study time frame, age 65 and over, and residing in the community before and after discharge from the hospital. Selected patients will have complex discharge plans including referrals to home care agencies, poly-pharmacy, multiple co-morbidities, history of repeated hospitalizations, and poor social support systems in the community. In addition, eligible patients will have at least one of eight admitting diagnoses, chosen for their high likelihood of requiring post-discharge home care needs. These diagnosis include: CHF, COPD, coronary artery disease, diabetes mellitus, stroke, hip fracture, peripheral vascular disease or cardiac arrhythmia. The GNP or fellow will then request permission from the patient's primary physician to do a one-time post-discharge home visit.

Exclusion Criteria:

Patients discharged to settings other than their homes (i.e. nursing home, sub-acute rehabilitation, etc.)Patients discharged to settings other than their homes (i.e. nursing home, sub-acute rehabilitation, etc.)

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00276367

Sponsors and Collaborators
Maimonides Medical Center
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Principal Investigator: Aleksandra Zagorin, MA, GNP-C, ANP-C Maimonides Medical Center
Layout table for additonal information Identifier: NCT00276367    
Other Study ID Numbers: 05/12/02
First Posted: January 13, 2006    Key Record Dates
Last Update Posted: May 13, 2015
Last Verified: May 2015
Additional relevant MeSH terms:
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Coronary Artery Disease
Coronary Disease
Myocardial Ischemia
Heart Diseases
Cardiovascular Diseases
Arterial Occlusive Diseases
Vascular Diseases