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PATient Navigator to rEduce Readmissions (PArTNER)

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ClinicalTrials.gov Identifier: NCT02114515
Recruitment Status : Completed
First Posted : April 15, 2014
Results First Posted : February 15, 2019
Last Update Posted : February 15, 2019
Sponsor:
Collaborators:
Patient-Centered Outcomes Research Institute
Society of Hospital Medicine
COPD Foundation
University of Kentucky
Mended Hearts
American Heart Association
Sickle Cell Disease Association of Illinois
AcademyHealth
The National Association of Social Workers Foundation
Respiratory Health Association
University of Illinois Sickle Cell Patient Council
National Jewish Health
Baystate Medical Center
Information provided by (Responsible Party):
Jerry Krishnan, University of Illinois at Chicago

Study Type Interventional
Study Design Allocation: Randomized;   Intervention Model: Parallel Assignment;   Masking: Single (Outcomes Assessor);   Primary Purpose: Health Services Research
Conditions Chronic Obstructive Pulmonary Disease
Heart Failure
Sickle Cell Disease
Myocardial Infarction
Pneumonia
Interventions Behavioral: Hospital usual care
Behavioral: Navigator intervention
Behavioral: Peer-led telephone support line
Enrollment 1029
Recruitment Details  
Pre-assignment Details  
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Period Title: Overall Study
Started 511 518
Completed 378 368
Not Completed 133 150
Reason Not Completed
Lost to Follow-up             52             55
Death             12             12
Withdrawal by Subject             4             22
Other             65             61
Arm/Group Title Usual Care Usual Care + PArTNER Total
Hide Arm/Group Description

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Total of all reporting groups
Overall Number of Baseline Participants 511 518 1029
Hide Baseline Analysis Population Description
[Not Specified]
Age, Categorical  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 511 participants 518 participants 1029 participants
<=18 years
0
   0.0%
0
   0.0%
0
   0.0%
Between 18 and 65 years
412
  80.6%
423
  81.7%
835
  81.1%
>=65 years
99
  19.4%
95
  18.3%
194
  18.9%
Age, Continuous  
Mean (Standard Deviation)
Unit of measure:  Years
Number Analyzed 511 participants 518 participants 1029 participants
49.9  (17.0) 49.8  (16.5) 49.9  (16.8)
Sex: Female, Male  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 511 participants 518 participants 1029 participants
Female
290
  56.8%
277
  53.5%
567
  55.1%
Male
221
  43.2%
241
  46.5%
462
  44.9%
Ethnicity (NIH/OMB)  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 511 participants 518 participants 1029 participants
Hispanic or Latino
40
   7.8%
49
   9.5%
89
   8.6%
Not Hispanic or Latino
471
  92.2%
468
  90.3%
939
  91.3%
Unknown or Not Reported
0
   0.0%
1
   0.2%
1
   0.1%
Race (NIH/OMB)  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 511 participants 518 participants 1029 participants
American Indian or Alaska Native
1
   0.2%
3
   0.6%
4
   0.4%
Asian
4
   0.8%
6
   1.2%
10
   1.0%
Native Hawaiian or Other Pacific Islander
0
   0.0%
0
   0.0%
0
   0.0%
Black or African American
424
  83.0%
423
  81.7%
847
  82.3%
White
62
  12.1%
72
  13.9%
134
  13.0%
More than one race
7
   1.4%
4
   0.8%
11
   1.1%
Unknown or Not Reported
13
   2.5%
10
   1.9%
23
   2.2%
Region of Enrollment  
Measure Type: Number
Unit of measure:  Participants
United States Number Analyzed 511 participants 518 participants 1029 participants
511 518 1029
1.Primary Outcome
Title PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 406 391
Mean (Standard Error)
Unit of Measure: T-score
-0.2  (0.5) -1.7  (0.5)
2.Primary Outcome
Title PROMIS Informational Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 405 391
Mean (Standard Error)
Unit of Measure: T-score
2.3  (0.6) 2.5  (0.6)
3.Secondary Outcome
Title PROMIS Emotional Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 401 390
Mean (Standard Error)
Unit of Measure: T-score
-0.1  (0.5) -0.1  (0.5)
4.Secondary Outcome
Title PROMIS Instrumental Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 403 391
Mean (Standard Error)
Unit of Measure: T-score
1.0  (0.5) 0.6  (0.5)
5.Secondary Outcome
Title PROMIS Global Health, Physical (v1.1, SF)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 408 389
Mean (Standard Error)
Unit of Measure: T-score
4.6  (0.4) 4.4  (0.4)
6.Secondary Outcome
Title PROMIS Global Health, Mental (v1.1, SF)
Hide Description

Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 408 389
Mean (Standard Error)
Unit of Measure: T-score
0.8  (0.4) 0.6  (0.4)
7.Secondary Outcome
Title PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 375 365
Mean (Standard Error)
Unit of Measure: T-score
0.3  (0.6) -1.1  (0.6)
8.Secondary Outcome
Title PROMIS Informational Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 373 363
Mean (Standard Error)
Unit of Measure: T-score
1.7  (0.6) 2.0  (0.7)
9.Secondary Outcome
Title PROMIS Emotional Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 372 363
Mean (Standard Error)
Unit of Measure: T-score
0.1  (0.5) -0.2  (0.5)
10.Secondary Outcome
Title PROMIS Instrumental Support (v2.0, SF4a)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 374 363
Mean (Standard Error)
Unit of Measure: T-score
0.8  (0.5) 1.0  (0.5)
11.Secondary Outcome
Title PROMIS Global Health, Physical (v1.1, SF)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 372 365
Mean (Standard Error)
Unit of Measure: T-score
3.4  (0.5) 3.6  (0.4)
12.Secondary Outcome
Title PROMIS Global Health, Mental (v1.1, SF)
Hide Description

Change in T-score from baseline to 60 days post discharge (60 days minus baseline).

A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.

Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 372 366
Mean (Standard Error)
Unit of Measure: T-score
-1.3  (0.5) 01.1  (0.4)
13.Secondary Outcome
Title Death
Hide Description Caregiver-reported and confirmed by EHR review
Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 502 497
Measure Type: Count of Participants
Unit of Measure: Participants
4
   0.8%
7
   1.4%
14.Secondary Outcome
Title Death
Hide Description Caregiver-reported and confirmed by EHR review
Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 493 488
Measure Type: Count of Participants
Unit of Measure: Participants
9
   1.8%
9
   1.8%
15.Secondary Outcome
Title Re-hospitalization or Death
Hide Description Confirmed by EHR review
Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 503 495
Measure Type: Count of Participants
Unit of Measure: Participants
100
  19.9%
112
  22.6%
16.Secondary Outcome
Title Re-hospitalization or Death
Hide Description Confirmed by EHR review
Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
[Not Specified]
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 493 487
Measure Type: Count of Participants
Unit of Measure: Participants
147
  29.8%
159
  32.6%
17.Secondary Outcome
Title ED Visit, Re-hospitalization, or Death
Hide Description Confirmed by EHR review
Time Frame 30 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 503 495
Measure Type: Count of Participants
Unit of Measure: Participants
156
  31.0%
154
  31.1%
18.Secondary Outcome
Title ED Visit, Re-hospitalization, or Death
Hide Description Confirmed by EHR review
Time Frame 60 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 494 487
Measure Type: Count of Participants
Unit of Measure: Participants
210
  42.5%
216
  44.4%
19.Secondary Outcome
Title Outpatient Healthcare Visit
Hide Description Self-reported
Time Frame 14 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 405 388
Measure Type: Count of Participants
Unit of Measure: Participants
137
  33.8%
112
  28.9%
20.Secondary Outcome
Title Outpatient Healthcare Visit
Hide Description EHR-reported
Time Frame 14 days post discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.
Arm/Group Title Usual Care Usual Care + PArTNER
Hide Arm/Group Description:

Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

Overall Number of Participants Analyzed 511 507
Measure Type: Count of Participants
Unit of Measure: Participants
236
  46.2%
232
  45.8%
Time Frame Adverse event data were collected from enrollment through 60 days after hospital discharge.
Adverse Event Reporting Description [Not Specified]
 
Arm/Group Title Usual Care Usual Care + PArTNER
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Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

All-Cause Mortality
Usual Care Usual Care + PArTNER
Affected / at Risk (%) Affected / at Risk (%)
Total   12/511 (2.35%)   12/518 (2.32%) 
Hide Serious Adverse Events
Usual Care Usual Care + PArTNER
Affected / at Risk (%) Affected / at Risk (%)
Total   12/511 (2.35%)   12/518 (2.32%) 
General disorders     
All-cause death * [1]  12/511 (2.35%)  12/518 (2.32%) 
*
Indicates events were collected by non-systematic assessment
[1]
Causes of death were not collected.
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Frequency Threshold for Reporting Other Adverse Events 5%
Usual Care Usual Care + PArTNER
Affected / at Risk (%) Affected / at Risk (%)
Total   0/511 (0.00%)   0/518 (0.00%) 
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
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Name/Title: Jerry A. Krishnan, MD, PhD
Organization: University of Illinois at Chicago
Phone: 312-413-3291
EMail: partner@uic.edu
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Responsible Party: Jerry Krishnan, University of Illinois at Chicago
ClinicalTrials.gov Identifier: NCT02114515    
Other Study ID Numbers: PCORI-IH 1211-4365
First Submitted: April 1, 2014
First Posted: April 15, 2014
Results First Submitted: October 20, 2017
Results First Posted: February 15, 2019
Last Update Posted: February 15, 2019