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Rural Options At Discharge Model of Active Planning (ROADMAP)

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ClinicalTrials.gov Identifier: NCT02684188
Recruitment Status : Completed
First Posted : February 17, 2016
Results First Posted : November 20, 2017
Last Update Posted : November 20, 2017
Sponsor:
Collaborator:
Providence St. Patrick Hospital, Missoula Montana
Information provided by (Responsible Party):
Tom Seekins, University of Montana

Study Type Interventional
Study Design Allocation: Non-Randomized;   Intervention Model: Parallel Assignment;   Masking: Single (Participant);   Primary Purpose: Supportive Care
Condition All Causes Hospital Admissions
Intervention Behavioral: Enhanced rural discharge and transition
Enrollment 127
Recruitment Details We recruited participants from among patients admitted to Saint Patrick Hospital, a regional referral hospital, from one of four counties. All four were non-metropolitan counties and three of the counties met the criteria of being a frontier county (population of less than 6 people per square mile).
Pre-assignment Details  
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Period Title: Overall Study
Started 77 50
Completed 75 47
Not Completed 2 3
Arm/Group Title Current Treatment Enhanced Transitions Planning Total
Hide Arm/Group Description Patients receive that current discharge planning services and supports.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient.

Total of all reporting groups
Overall Number of Baseline Participants 77 50 127
Hide Baseline Analysis Population Description
[Not Specified]
Age, Continuous  
Mean (Full Range)
Unit of measure:  Years
Number Analyzed 77 participants 50 participants 127 participants
59.9
(30 to 74)
63.2
(38 to 74)
61.2
(30 to 74)
Sex: Female, Male  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 77 participants 50 participants 127 participants
Female
34
  44.2%
21
  42.0%
55
  43.3%
Male
43
  55.8%
29
  58.0%
72
  56.7%
Ethnicity (NIH/OMB)  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 77 participants 50 participants 127 participants
Hispanic or Latino
0
   0.0%
0
   0.0%
0
   0.0%
Not Hispanic or Latino
72
  93.5%
47
  94.0%
119
  93.7%
Unknown or Not Reported
5
   6.5%
3
   6.0%
8
   6.3%
Race (NIH/OMB)  
Measure Type: Count of Participants
Unit of measure:  Participants
Number Analyzed 77 participants 50 participants 127 participants
American Indian or Alaska Native
7
   9.1%
6
  12.0%
13
  10.2%
Asian
0
   0.0%
0
   0.0%
0
   0.0%
Native Hawaiian or Other Pacific Islander
1
   1.3%
0
   0.0%
1
   0.8%
Black or African American
0
   0.0%
0
   0.0%
0
   0.0%
White
67
  87.0%
43
  86.0%
110
  86.6%
More than one race
0
   0.0%
0
   0.0%
0
   0.0%
Unknown or Not Reported
2
   2.6%
1
   2.0%
3
   2.4%
Region of Enrollment   [1] 
Measure Type: Number
Unit of measure:  Participants
United States Number Analyzed 77 participants 50 participants 127 participants
77 50 127
[1]
Measure Description: Participants recruited from among patients from four rural counties in St. Patrick Hospital's the catchment area, including Beaverhead, Lake, Powell, and Sanders Counties Montana.
Patient Activation Measure (PAM10)   [1] 
Mean (Full Range)
Unit of measure:  Units on a scale
Number Analyzed 77 participants 50 participants 127 participants
65.1
(39 to 100)
73.8
(45 to 100)
69.9
(39 to 100)
[1]
Measure Description: Patients completed the 10-item Patient Activation Measure (PAM10) questionnaire measuring a patient's confidence in their knowledge, skills, and abilities to manage their health once they were discharged from a hospital. Patients indicated whether they strongly agreed, agreed, disagreed, or strongly disagreed with each statement. A patient could also indicate that a particular item was not applicable to their situation. Total scores ranged from 0.0 to 100.0. Higher scores indicated greater confidence in their capacity for self-management.
Length of Stay, Acuity, Co-morbidity, and Emergency Department Visits (LACE+)   [1] [2] 
Mean (Full Range)
Unit of measure:  Units on a scale
Number Analyzed 62 participants 50 participants 112 participants
42.2
(13 to 84)
49.7
(22 to 80)
46.3
(13 to 84)
[1]
Measure Description: The LACE+ uses a proprietary algorithm to calculate the likelihood of a patient's hospital readmission based on information derived from the patient's electronic medical record. Generally, higher scores reflect higher risk. Scores range from 0 to 100. A score of 28 or less is categorized as low risk. A score of 29 to 58 is categorized as medium risk. A score of 59 or higher is categorized as high risk.
[2]
Measure Analysis Population Description: We analyzed LACE+ data for 112 patients as the electronic medical record did not establish this measure until after the study started.
1.Primary Outcome
Title Hospital Re-admissions Analyzed by Poisson Regression
Hide Description Number of admissions to any hospital reported by the patients after discharge from a regional hospital to one of four rural counties.
Time Frame 3, 7 ,14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Services Enhanced Discharge & Rural Transition Support
Hide Arm/Group Description:
Patients received standard discharge planning; the baseline and return to baseline groups were combined to form a single standard discharge group

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of recovery supports to the patient.

Enhanced Discharge Planning & Rural Transition Support: While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: Hospital Readmission
3 days after discharge 17 4
7 days after discharge 21 5
14 days after discharge 23 7
21 days after discharge 25 7
30 days after discharge 25 9
60 days after discharge 28 10
90 days after discharge 26 12
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 3 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.030
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 3, 112(68 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 7 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.025
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 7, 110 (66 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 14 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.037
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 14, 104 (61 baseline and 43 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 21 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.011
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 21, 98 (57 baseline and 41 intervention) patients were used in this analysis.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 30 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.050
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 30, 95 (56 baseline and 39 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 60 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.055
Comments [Not Specified]
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 60, 87 (53 baseline and 34 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the cumulative number of hospital visits for day 90 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 90.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.137
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 90, 83 (49 baseline and 34 intervention) patients were used in this analysis.
2.Primary Outcome
Title Hospital Re-admissions Analyzed by Logistic Regression
Hide Description Proportion of patients who self-report at least one hospital readmission to any hospital after discharge from a regional hospital to one of four rural counties.
Time Frame 3, 7 ,14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Services Enhanced Discharge & Rural Transition Support
Hide Arm/Group Description:
Patients received standard discharge planning; the baseline and return to baseline groups were combined to form a single standard discharge group

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of recovery supports to the patient.

Enhanced Discharge Planning & Rural Transition Support: While in the treating hospital, patients from small towns and rural communities are engaged in package of procedures designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs and the provision of enhanced recovery supports to the patient.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: proportion of patients rehospitalized
3 days after discharge Number Analyzed 68 participants 44 participants
0.10 0.07
7 days after discharge Number Analyzed 66 participants 44 participants
0.12 0.07
14 days after discharge Number Analyzed 61 participants 43 participants
0.11 0.09
21 days after discharge Number Analyzed 57 participants 41 participants
0.16 0.10
30 days after discharge Number Analyzed 56 participants 39 participants
0.16 0.18
60 days after discharge Number Analyzed 53 participants 34 participants
0.19 0.18
90 days after discharge Number Analyzed 49 participants 34 participants
0.18 0.21
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 3 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.279
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 3, 112(68 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 7 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.211
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 7, 110 (66 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 14 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.424
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 14, 104 (61 baseline and 43 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 21 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.191
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 21, 98 (57 baseline and 41 intervention) patients were used in this analysis.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 30 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.478
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 30, 95 (56 baseline and 39 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 60 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.452
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 60, 87 (53 baseline and 34 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Services, Enhanced Discharge & Rural Transition Support
Comments [Not Specified]
Type of Statistical Test Superiority
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 90 (null hypothesis); H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 90.
Statistical Test of Hypothesis P-Value 0.381
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 90, 83 (49 baseline and 34 intervention) patients were used in this analysis.
3.Primary Outcome
Title Emergency Department (ED) Visits Analyzed by Poisson Regression
Hide Description Number of self-reported visits to the emergency department of any hospital reported by patients after discharge from a regional hospital to one of four rural counties.
Time Frame 3, 7, 14, 21,30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services;the baseline and return to baseline groups were combined to form a single standard discharge group

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: Emergency Department Visits
3 days after discharge Number Analyzed 70 participants 45 participants
9 6
7 days after discharge Number Analyzed 68 participants 45 participants
18 11
14 days after discharge Number Analyzed 63 participants 44 participants
27 17
21 days after discharge Number Analyzed 59 participants 42 participants
38 19
30 days after discharge Number Analyzed 58 participants 40 participants
43 19
60 days after discharge Number Analyzed 55 participants 35 participants
47 19
90 days after discharge Number Analyzed 51 participants 35 participants
48 21
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of hospital visits for day 3 (null hypothesis); H1: The cumulative number of hospital visits for the standard discharge group is greater than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.502
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 3, 115 (70 baseline and 45 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 7 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.286
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 7, 113 (68 baseline and 45 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 14 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.347
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 14, 107 (63 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 21 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.250
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 21, 101 (59 baseline and 42 intervention) patients were used in this analysis.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 30 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.220
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 30, 98 (58 baseline and 40 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 60 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.116
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 60, 90 (55 baseline and 35 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of ED visits for day 90 (null hypothesis); H1: The cumulative number of ED visits for the standard discharge group is greater than that for the enhanced discharge group for day 90.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.126
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 90, 86 (51 baseline and 35 intervention) patients were used in this analysis.
4.Primary Outcome
Title Emergency Department (D) Visits Analyzed by Logistic Regression
Hide Description Proportion of patients who report at least one emergency department visit after discharge from a regional hospital to one of four rural counties.
Time Frame 3, 7, 14, 21,30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services;the baseline and return to baseline groups were combined to form a single standard discharge group

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: participants with at least one ED visit
3 days after discharge Number Analyzed 70 participants 45 participants
0.10 0.09
7 days after discharge Number Analyzed 68 participants 45 participants
0.15 0.11
14 days after discharge Number Analyzed 63 participants 44 participants
0.16 0.14
21 days after discharge Number Analyzed 59 participants 42 participants
0.22 0.19
30 days after discharge Number Analyzed 58 participants 40 participants
0.24 0.20
60 days after discharge Number Analyzed 55 participants 35 participants
0.29 0.23
90 days after discharge Number Analyzed 51 participants 35 participants
.29 0.23
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 3; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.597
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 3, 115 (70 baseline and 45 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 7; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.504
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 7, 113 (68 baseline and 45 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 14; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.558
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 14, 107 (63 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 21; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.472
Comments Comments (covariates): P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 21, 101 (59 baseline and 42 intervention) patients were used in this analysis.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 30; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.462
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 30, 98 (58 baseline and 40 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 60; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.394
Comments P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 60, 90 (55 baseline and 35 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the proportion of patients with at least one ED visits by day 90; H1: The proportion of patients with at least one ED visit for the standard discharge group is greater than that for the enhanced discharge group for day 90.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.368
Comments Comments (covariates): P-values comparing the counts for the 2 groups after adjusting for PAM10.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 90, 86 (51 baseline and 35 intervention) patients were used in this analysis.
5.Primary Outcome
Title Primary Care Provider (PCP) Visits Analyzed by Poisson Regression
Hide Description This reflects the number of visits to a patient's local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge.
Time Frame 3, 7, 14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to a regional referral hospital for treatment, who enrolled in the study and were discharged to one of four rural counties.
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: Primary Care Provider Visits
3 days after discharge Number Analyzed 70 participants 44 participants
7 2
7 days after discharge Number Analyzed 67 participants 44 participants
27 19
14 days after discharge Number Analyzed 62 participants 43 participants
54 45
21 days after discharge Number Analyzed 58 participants 40 participants
71 50
30 days after discharge Number Analyzed 57 participants 38 participants
91 49
60 days after discharge Number Analyzed 54 participants 33 participants
135 59
90 days after discharge Number Analyzed 50 participants 33 participants
148 83
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments The following hypotheses were tested: H0: There is no difference in the cumulative number of PCP visits for day 3 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.946
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE+ score.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 3, 114 (70 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 7 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.613
Comments [Not Specified]
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 7, 111 (67 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 14 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.541
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE+ score.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 14, 105 (62 baseline and 43 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 21 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.765
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 21, 98 (58 baseline and 40 intervention) patients were used in this analysis.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 30 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.919
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE+ score.
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 30, 95 (57 baseline and 38 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 60 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.999
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score.
Method Poisson regression
Comments P-values comparing the counts for the 2 groups after adjusting for sex, age, number in household, county, and LACE score.
Other Statistical Analysis For day 60, 87 (54 baseline and 33 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 90 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 90.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.995
Comments [Not Specified]
Method Poisson regression
Comments [Not Specified]
Other Statistical Analysis For day 90, 83 (50 baseline and 33 intervention) patients were used in this analysis.
6.Primary Outcome
Title Primary Care Provider (PCP) Visits Analyzed by Logistic Regression
Hide Description This reflects the proportion of patients who reported at least one visit to a their local primary care provider at 3, 7, 14, 21,30, 60, and 90 days after discharge.
Time Frame 3, 7, 14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to a regional referral hospital for treatment, who enrolled in the study and were discharged to one of four rural counties.
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Measure Type: Number
Unit of Measure: Proportion with Primary Care Visits
3 days after discharge Number Analyzed 70 participants 44 participants
0.07 0.05
7 days after discharge Number Analyzed 67 participants 44 participants
0.31 0.32
14 days after discharge Number Analyzed 62 participants 43 participants
0.47 0.51
21 days after discharge Number Analyzed 58 participants 40 participants
0.60 0.53
30 days after discharge Number Analyzed 57 participants 38 participants
0.63 0.55
60 days after discharge Number Analyzed 54 participants 33 participants
0.74 0.64
90 days after discharge Number Analyzed 50 participants 33 participants
0.80 0.70
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments : H0: There is no difference in the cumulative number of PCP visits for day 3 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 3.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.717
Comments This Hypothesis was tested with no adjustments for covariates since none were significant.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 3, 114 (70 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 2 Hide Statistical Analysis 2
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 7 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 7.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.479
Comments This Hypothesis was tested with no adjustments for covariates since none were significant.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 7, 111 (67 baseline and 44 intervention) patients were used in this analysis.
Show Statistical Analysis 3 Hide Statistical Analysis 3
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 14 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 14.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.329
Comments [Not Specified]
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 14, 105 (62 baseline and 43 intervention) patients were used in this analysis.
Show Statistical Analysis 4 Hide Statistical Analysis 4
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 21 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 21.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.780
Comments [Not Specified]
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis This Hypothesis was tested with no adjustments for covariates since none were significant.
Show Statistical Analysis 5 Hide Statistical Analysis 5
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 30 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 30.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.779
Comments This Hypothesis was tested with no adjustments for covariates since none were significant.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 30, 95 (57 baseline and 38 intervention) patients were used in this analysis.
Show Statistical Analysis 6 Hide Statistical Analysis 6
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 60 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 60.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.848
Comments This Hypothesis was tested with no adjustments for covariates since none were significant.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 60, 87 (54 baseline and 33 intervention) patients were used in this analysis.
Show Statistical Analysis 7 Hide Statistical Analysis 7
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments H0: There is no difference in the cumulative number of PCP visits for day 90 (null hypothesis); H1: The cumulative number of PCP visits for the standard discharge group is less than that for the enhanced discharge group for day 90.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.857
Comments This Hypothesis was tested with no adjustments for covariates since none were significant.
Method Regression, Logistic
Comments [Not Specified]
Other Statistical Analysis For day 90, 83 (50 baseline and 33 intervention) patients were used in this analysis.
7.Secondary Outcome
Title Short Form (SF12) Physical Health Score
Hide Description The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0.
Time Frame 3, 7, 14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Mean (Standard Deviation)
Unit of Measure: units on a scale
3 days after discharge 35.1  (7.8) 36.3  (7.9)
7 days after discharge 34.7  (6.6) 35.1  (7.5)
14 days after discharge 35.7  (6.4) 36.0  (6.7)
21 days after discharge 36.3  (6.1) 36.4  (5.9)
30 days after discharge 37.3  (6.0) 37.2  (7.1)
60 days after discharge 39.2  (5.8) 39.0  (6.5)
90 days after discharge 40.3  (6.0) 39.9  (6.1)
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments The following hypotheses were tested: Hoi: There is no difference in mean SF12 Physical Health scores between the standard and enhanced discharge groups (null hypothesis); H1i: The mean SF12 Physical Health scores differ between the standard and enhanced discharge groups.
Type of Statistical Test Equivalence
Comments A repeated measures ANOVA model was used to model the SF12 Physical Health score as a function of treatment group. The likelihood ratio test was used to calculate the p-values for the treatment effect and covariates. No adjustments for multiple comparisons were made. Hypotheses were tested after adjusting for the effects of the repeated measures, patient age, and the number of people in a household. All hypotheses were 2-sided and p-values < 0.05 were considered statistically significant.
Statistical Test of Hypothesis P-Value 0.371
Comments The P-value comparing the means for the 2 groups averaged across the 7 days is p = 0.371, after adjusting for covariates.
Method ANOVA
Comments [Not Specified]
8.Secondary Outcome
Title Short Form (SF12) Mental Health Score
Hide Description The SF12 is a twelve-item standardized questionnaire that measures overall, physical health, and mental health. Patients rate each item on an ordinal scale. Data are analyzed using a proprietary algorithm. Scores range from 0 to 100. Higher scores reflect a better health status. The analysis creates an overall health score and sub scores that reflect physical health and mental health. Both Physical and Mental Health Composite Scales combine the 12 items in such a way that they compare to a national norm of a mean score of 50.0 and a standard deviation of 10.0.
Time Frame 3, 7, 14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Mean (Standard Deviation)
Unit of Measure: units on a scale
3 days after discharge 47.8  (12.1) 47.2  (11.2)
7 days after discharge 50.0  (12.5) 49.3  (13.0)
14 days after discharge 51.8  (10.9) 50.9  (10.5)
21 days after discharge 53.9  (10.6) 54.5  (10.5)
30 days after discharge 53.8  (10.0) 53.4  (11.0)
60 days after discharge 54.4  (8.7) 53.6  (8.9)
90 days after discharge 54.8  (10.2) 54.4  (9.2)
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments The following hypotheses were tested: Hoi: There is no difference in mean SF-12 Mental Health scores between the standard and enhanced discharge groups (null hypothesis); H1i: The mean SF-12 Mental Health scores differ between the standard and enhanced discharge groups.
Type of Statistical Test Equivalence
Comments A repeated measures ANOVA model was used to model the SF-12 Mental Health score as a function of treatment group. The likelihood ratio test was used to calculate the p-values for the treatment effect and covariates. No adjustments for multiple comparisons were made. Hypotheses were tested after adjusting for the effects of the repeated measures, patient age, income, and county. All hypotheses were 2-sided and p-values < 0.05 were considered statistically significant.
Statistical Test of Hypothesis P-Value 0.232
Comments The P-value comparing the means for the 2 groups averaged across the 7 days is p = 0.232, after adjusting for covariates.
Method ANOVA
Comments [Not Specified]
9.Secondary Outcome
Title Care Transition Measure (CTM3)
Hide Description The CTM3 is a three-item standardized questionnaire to measures patients’ perspectives on coordination of hospital discharge care. Patients rate whether they strongly agree, agree, disagree, or strongly disagree with three items (hospital staff too my preferences into account, I had a good idea what I was responsible for once I left the hospital, and I clearly understood the purpose for taking each of my medications). They may also rate an items as not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better discharge care.
Time Frame 3 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 68 44
Mean (Standard Deviation)
Unit of Measure: Survey Response Scores
0.86  (0.18) 0.80  (0.26)
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments The following hypotheses were tested: H0: There is no difference in the mean CTM3 score between the standard and enhanced discharge groups (null hypothesis); H1: Patients in the enhanced discharge group will have a higher mean CTM3 rating than patients in the standard discharge group.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.806
Comments [Not Specified]
Method ANCOVA
Comments [Not Specified]
Other Statistical Analysis An analysis of covariance was used to model the CTM3 discharge planning score as a function of treatment group. An ANOVA F-test was used to calculate the p-values for the treatment effect and covariates. No adjustments for multiple comparisons were made. Hypotheses were tested after adjusting for the effects of patient age and income. The hypothesis test for the group comparison was 1-sided, hypotheses to assess significance of covariates were 2-sided, and p-values < 0.05 were considered statistically significant. The covariates Sex, County, Number in Household, LACE+ score, and PAM10 score did not differ in their mean CTM3 scores so were not retained in the model.
10.Secondary Outcome
Title Rural Transition Measure (RTM14)
Hide Description The RTM14 is a fourteen-item questionnaire to measures patients’ perspectives on the delivery of transition services and supports after discharge from a regional hospital to a small town or rural community. Patients respond by indicating whether they strongly disagree, disagree, agree, or strongly agree with each of the 14 items. Patients may also indicate whether an item is not applicable to their situation. Ratings are converted to a scale that ranges from 0 to 100. Higher scores reflect better transition service performance.
Time Frame 7, 14, 21, 30, 60, and 90 days after discharge
Hide Outcome Measure Data
Hide Analysis Population Description
Patients between 18 and 75 years old admitted to regional referral hospital for treatment, who enrolled in study and were discharged to one of four rural counties
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description:
Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

Overall Number of Participants Analyzed 77 50
Mean (Standard Deviation)
Unit of Measure: Survey Response Scores
7 days after discharge 0.854  (0.173) 0.884  (0.149)
14 days after discharge 0.897  (0.131) 0.873  (0.161)
21 days after discharge 0.922  (0.118) 0.876  (0.158)
30 days after discharge 0.902  (0.133) 0.895  (0.147)
60 days after discharge 0.901  (0.120) 0.924  (0.092)
90 days after discharge 0.901  (0.163) 0.911  (0.107)
Show Statistical Analysis 1 Hide Statistical Analysis 1
Statistical Analysis Overview Comparison Group Selection Standard Hospital Discharge Planning Services, Enhanced Discharge Planning and Rural Transition Supports
Comments The following hypotheses were tested: H0: There is no difference in the mean RTM14 score between the standard and enhanced discharge groups (null hypothesis); H1: Patients in the enhanced discharge group will have a higher mean RTM14 rating than patients in the standard discharge group.
Type of Statistical Test Superiority
Comments [Not Specified]
Statistical Test of Hypothesis P-Value 0.742
Comments [Not Specified]
Method ANOVA
Comments [Not Specified]
Other Statistical Analysis A repeated measures ANOVA model (over the 6 time measurement periods) was used to model the RTM14 score as a function of treatment group. The likelihood ratio test was used to calculate the p-values for the treatment effect and covariates. No adjustments for multiple comparisons were made. Hypotheses were tested after adjusting for the effects of the repeated measures, patient age, income, and whether or not a patient had visited a hospital or ED prior to that day. The hypothesis test for the group comparison was 1-sided, hypotheses to assess significance of covariates were 2-sided, and p-values < 0.05 were considered statistically significant. The covariates Sex, Number in household, LACE+ score, and PAM10 score were not significant in explaining SF-12 scores so were not retained in the model.
Time Frame Up to 90 days post discharge
Adverse Event Reporting Description [Not Specified]
 
Arm/Group Title Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Hide Arm/Group Description Patients receive standard discharge planning services.

The intervention consists of a package of procedures that enhances supports during the transitions from the hospital to recovery at home, including a structured needs assessment that produces a plan that matches available rural community service providers to a patient's transition needs and the provision of recovery supports to the patient.

Enhanced Transitions Planning: While in the treating hospital, patients from small towns and rural communities are engaged in a process designed to improve the transitions home, including a functional needs assessment that produces a plan that matches available rural community service providers to a patient's transitions needs. Once home, a Local Community Transition Coordinator provides support to address needs.

All-Cause Mortality
Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Affected / at Risk (%) Affected / at Risk (%)
Total   2/77 (2.60%)   0/50 (0.00%) 
Show Serious Adverse Events Hide Serious Adverse Events
Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Affected / at Risk (%) Affected / at Risk (%)
Total   0/77 (0.00%)   0/50 (0.00%) 
Show Other (Not Including Serious) Adverse Events Hide Other (Not Including Serious) Adverse Events
Frequency Threshold for Reporting Other Adverse Events 0%
Standard Hospital Discharge Planning Services Enhanced Discharge Planning and Rural Transition Supports
Affected / at Risk (%) Affected / at Risk (%)
Total   0/77 (0.00%)   0/50 (0.00%) 
The overall sample was small due to the rural focus of the program. The sample size for emergency department visits and hospitalizations was low, making it difficult to detect differences.
Certain Agreements
All Principal Investigators ARE employed by the organization sponsoring the study.
Results Point of Contact
Layout table for Results Point of Contact information
Name/Title: Tom Seekins, Ph.D.
Organization: University of Montana
Phone: 2432654 ext 406
EMail: TOm.Seekins@UMontana.edu
Layout table for additonal information
Responsible Party: Tom Seekins, University of Montana
ClinicalTrials.gov Identifier: NCT02684188     History of Changes
Other Study ID Numbers: 177-15
First Submitted: December 30, 2015
First Posted: February 17, 2016
Results First Submitted: July 31, 2017
Results First Posted: November 20, 2017
Last Update Posted: November 20, 2017