Patient AdmissionEDPPNCT01378234
Enhanced Discharge Planning Program -- Prospective
A study testing Enhanced Discharge Planning Program transitional care in people with Patient Admission and Patient Discharge, run by Rush University Medical Center at 1 site in United States.
Trial summary
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. Read more about this study
- Who is it for?
- Ages 65 years and older
- Conditions the study is for
- Patient Admission, Patient Discharge
- What is being tested?
- Enhanced Discharge Planning Program transitional care
- Type of treatment
- Lifestyle or therapy programme
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 740 participants
- Where
- 1 siteUnited States
- Study dates
- Jun 2009to Jul 2010
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 65 years and older
- All sexes
- No healthy volunteers
- Older adult
Who may be able to join
- Must meet all the following criteria:
- Aged 65+
- English speaking
- Returning home after discharge
- 7+ medication prescribed
- Must also meet one additional criterion:
Show all 14Show fewer
- Lives alone
- Without a source of emotional support
- Without a support system for care in place
- Discharged with a service referral
- High risk for falls
- Inpatient hospitalization within 12 months
- Identified in depth psychosocial need
- High risk medication prescribed
Who cannot join
- Primary diagnosis of transplant
- Non-English speaking
- Discharged to a facility
Trial locations and contacts
1 site in 1 country.
United States1 site
Rush University Medical Center
Chicago, Illinois, 60612
About this study
Official title: The Impact of a Social Work Driven Transitional Care Model on Health Outcomes for At-Risk Older Adults
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
Read the detailed description
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
Research Process
- Rush University Medical Center inpatients receive the Enhanced Discharge Planning Program information sheet in the Rush patient education packet. All Rush inpatients will receive an informational sheet about the EDPP study, with an exception of pediatric and labor/delivery inpatients. The sheet will be included in the patient education packets distributed by Rush. This will make patients aware of the EDPP program before they leave the hospital and prepare them for a call once they return home.
- Eligible patients are referred to the Enhanced Discharge Planning Program at their point of discharge via an electronic referral report through Epic. EDPP receives an electronic referral report of all patients meeting the specified referral criteria. Referral is dependent on discharge data recorded by Rush nurses and case managers in the Epic electronic medical record and generated at the point of discharge. The electronic system ensures a streamlined, standardized referral process by creating an automatic referral based upon documentation completed as part of nurse's and case manager's typical workflow. An anticipated 720 patients will be electronically referred during the duration of the study.
- The Enhanced Discharge Planning Program project coordinator receives the daily referral report and inputs patients into the block randomization scheme. The project coordinator will input referrals into the existing block randomization scheme after receiving the electronic report at the beginning of the day. Referrals will be copied into the scheme in the same order as reported - sorted by episode number - to reduce bias. Patients assigned to the intervention group will be forwarded to the EDPP social workers. The usual care group will be managed by the project coordinator and student interns under her direct supervision.
- The Enhanced Discharge Planning Program social worker contacts the intervention group to provide clinical care and obtain consent.
- Conditions
- Patient Admission, Patient Discharge
- Being tested
- Enhanced Discharge Planning Program transitional care
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Enhanced Discharge Planning Program transitional careBehavioural
Also called EDPP
Enhanced Discharge Planning Program (EDPP) provides telephonic short-term post-discharge social work services that assess and intervene from a biopsychosocial perspective for at-risk older adults returning home after an inpatient hospitalization. EDPP follows a four-step process to with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge:
- Ensure patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs
- Connect patients to outpatient health services (ex: home health, in-home services, dialysis, radiology, laboratory services, specialty care) with particular emphasis on the first physician follow-up appointment
- Supporting caregivers to reduce stress and burden
| Study group | Role | What they receive |
|---|---|---|
| EDPP Intervention | Experimental | Receive EDPP transitional care intervention from social worker upon hospital discharge Receives: Behavioral: Enhanced Discharge Planning Program transitional care |
| Usual Care | No intervention | Receive usual care upon hospital discharge |
What is being measured
The primary outcome is the main question the study is designed to answer.
Readmissions
Readmission to hospital within 30 days after index discharge date
Measured: 30 days
Readmissions
Readmission to hospital within 60 days of index discharge date
Measured: 60 days
Readmissions
Readmission to hospital within 90 days of index discharge date
Measured: 90 days
Readmissions
Readmission to hospital within 180 days of index discharge date
Measured: 180 days
Secondary outcomes (4)
Stress
Patient and caregiver stress, self-reported
Measured: 30 days
Physician follow-up
Appointment made, kept with doctor
Measured: 30 days
Mortality
patient's Mortality will be monitored and documented.
Measured: 30 days
Patient needs
Audit of problems detected post-discharge
Measured: 30 days
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted22 Jun 2011 (estimated)
- Study startJun 2009
- Primary completionJul 2010
- Study completionJul 2010
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Patient AdmissionStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 740 participants (actual)
Sponsor and investigators
- Lead sponsor
- Rush University Medical Center
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Robyn Golden, Rush University Medical Center
- Investigators
- Robyn Golden, LCSW, Principal investigator, Rush University Medical Center
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT01378234
- Sponsor's protocol ID
- 08121903-IRB02
- Acronym
- EDPP
- Status last verified
- Sep 2023
- First submitted
- 17 Jun 2011
- Last updated
- 8 Sep 2023
- Results posted
- No
- Data monitoring committee
- No
Study at a glance
From the registry record, last updated by the sponsor on 8 Sep 2023. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- The Impact of a Social Work Driven Transitional Care Model on Health Outcomes for At-Risk Older Adults
- ClinicalTrials.gov ID
- NCT01378234
- Acronym / sponsor ID
- EDPP / 08121903-IRB02
- Conditions
- Patient Admission, Patient Discharge
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 740 participants (actual)
- Lead sponsor
- Rush University Medical CenterUniversity, hospital or other
- Study start
- Jun 2009
- Primary completion
- Jul 2010 (actual)
- Study completion
- Jul 2010 (actual)
- First posted
- 22 Jun 2011 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
Detailed description
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge. This is achieved through telephonic care coordination facilitated by social workers. EDPP social workers ensure full implementation of the discharge plan, assist with coordinating community resources and follow-up appointments, and intervene around other issues that may arise as a result of a complex transition.
The EDPP intervention is currently being offered to some older adult patients discharged from Rush University Medical Center. Case managers refer older adult patients on selected units who they believe may be at risk for adverse events post-discharge. While this service is being provided to patients, it has not yet been formally evaluated. This randomized controlled trial will provide data necessary for a more rigorous evaluation of the efficacy of this intervention.
Research Process
- Rush University Medical Center inpatients receive the Enhanced Discharge Planning Program information sheet in the Rush patient education packet. All Rush inpatients will receive an informational sheet about the EDPP study, with an exception of pediatric and labor/delivery inpatients. The sheet will be included in the patient education packets distributed by Rush. This will make patients aware of the EDPP program before they leave the hospital and prepare them for a call once they return home.
- Eligible patients are referred to the Enhanced Discharge Planning Program at their point of discharge via an electronic referral report through Epic. EDPP receives an electronic referral report of all patients meeting the specified referral criteria. Referral is dependent on discharge data recorded by Rush nurses and case managers in the Epic electronic medical record and generated at the point of discharge. The electronic system ensures a streamlined, standardized referral process by creating an automatic referral based upon documentation completed as part of nurse's and case manager's typical workflow. An anticipated 720 patients will be electronically referred during the duration of the study.
- The Enhanced Discharge Planning Program project coordinator receives the daily referral report and inputs patients into the block randomization scheme. The project coordinator will input referrals into the existing block randomization scheme after receiving the electronic report at the beginning of the day. Referrals will be copied into the scheme in the same order as reported - sorted by episode number - to reduce bias. Patients assigned to the intervention group will be forwarded to the EDPP social workers. The usual care group will be managed by the project coordinator and student interns under her direct supervision.
- The Enhanced Discharge Planning Program social worker contacts the intervention group to provide clinical care and obtain consent.
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| EDPP Intervention | Experimental | Behavioral: Enhanced Discharge Planning Program transitional careReceive EDPP transitional care intervention from social worker upon hospital discharge |
| Usual Care | No intervention | –Receive usual care upon hospital discharge |
Who may qualify
- Ages
- 65 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (14 listed)
- Must meet all the following criteria:
- Aged 65+
- English speaking
- Returning home after discharge
- 7+ medication prescribed
Key exclusion criteria (3 listed)
- Primary diagnosis of transplant
- Non-English speaking
- Discharged to a facility
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Enhanced Discharge Planning Program transitional careAlso: EDPPEnhanced Discharge Planning Program (EDPP) provides telephonic short-term post-discharge social work services that assess and intervene from a biopsychosocial perspective for at-risk older adults returning home after an inpatient hospitalization. EDPP follows a four-step process to with three guiding tasks to reach the goal of preventing avoidable adverse events post-discharge: 1. Ensure patients understand the discharge plan of care and receive recommended services while screening for unidentified medical or social needs 2. Connect patients to outpatient health services (ex: home health, in-home services, dialysis, radiology, laboratory services, specialty care) with particular emphasis on the first physician follow-up appointment 3. Supporting caregivers to reduce stress and burden | Behavioural | EDPP Intervention |
Primary outcome
Readmissions
Time frame: 30 days
Readmission to hospital within 30 days after index discharge date
Readmissions
Time frame: 60 days
Readmission to hospital within 60 days of index discharge date
Readmissions
Time frame: 90 days
Readmission to hospital within 90 days of index discharge date
Readmissions
Time frame: 180 days
Readmission to hospital within 180 days of index discharge date
4 secondary outcomes
Stress
Time frame: 30 days
Physician follow-up
Time frame: 30 days
Mortality
Time frame: 30 days
Patient needs
Time frame: 30 days
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 8 Sep 2023.
Related trials for Patient Admission
Not yet recruitingObservational study
Diaphragm Response in Elderly for Acute Monitoring
Acute Dyspnea, Acute Respiratory Failure
Recruiting
Characterization and Longitudinal Monitoring of Muscular Phenotype in Patients Admitted to Intensive Care for Sepsis
Sepsis, Myopathy Critical Illness
Not yet recruiting
Transitioning Recently Admitted Patients With Non-Insulin and Insulin-treated Type 2 Diabetes to Innovative Glucose Monitoring
Type 2 Diabetes
Recruiting
A Prospective Study of Cardiovascular Risk of Patients Admitted for Acute Exacerbation of COPD
COPD
RecruitingObservational study
Analysis of Life-threatening ARrhythMias After Acute Coronary Syndrome
Acute Coronary Syndromes (ACS), Ventricular Tachycardia (VT)
Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Robyn Golden, LCSW principal investigator
Rush University Medical Center
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Enhanced Discharge Planning Program transitional care in people with Patient Admission and Patient Discharge, run by Rush University Medical Center at 1 site in United States.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 14 inclusion and 3 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 8 Sep 2023. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Readmissions (time frame: 30 days). The study lists 4 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 8 Sep 2023.