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Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence (ACHIEVE)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT02354482
Recruitment Status : Completed
First Posted : February 3, 2015
Results First Posted : November 26, 2019
Last Update Posted : November 26, 2019
Sponsor:
Collaborators:
University of Pennsylvania
Boston Medical Center
Westat
Kaiser Permanente
Telligen, Inc.
University of Illinois at Chicago
Hospital Research & Education Trust, American Hospital Association
Joint Commission Resources
America's Essential Hospitals
Louisiana State University Health Sciences Center Shreveport
United Hospital Fund
Caregiver Action Network
National Association of Area Agencies on Aging
Information provided by (Responsible Party):
Mark Williams, University of Kentucky

Brief Summary:
Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.

Condition or disease Intervention/treatment
Care Transitions Behavioral: Patient Communication and Care Management Behavioral: Home-Based Trust, Plain Language, and Coordination Behavioral: Hospital-Based Trust, Plain Language, and Coordination Behavioral: Patient/Caregiver Assessment and Provider Information Exchange Behavioral: Assessment and Teach Back Other: Standard of Care (Reference)

Detailed Description:

Patients in the U.S. suffer harm too often as they move between sites of health care, and their caregivers experience significant burden. Unfortunately, the usual approach to health care does not support continuity and coordination during such "care transitions" between hospitals, clinics, home or nursing homes. Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and ER visits.

Specific Aims:

  1. Identify the transitional care outcomes and components that matter most to patients and caregivers.
  2. Determine which evidence-based transitional care components (TCCs) or clusters most effectively yield patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different types of care settings and communities.
  3. Identify barriers and facilitators to the implementation of specific TCCs or clusters of TCCs for different types of care settings and communities.
  4. Develop recommendations for dissemination and implementation of the findings on the best evidence regarding how to achieve optimal TC services and outcomes for patients, caregivers and providers.

Study Design:

Capitalizing on the opportunity for a natural experiment observational study, the research team will conduct qualitative and quantitative studies. This 52-month study is divided into two distinct phases. During the first phase, Project ACHIEVE will use focus groups, with patients, caregivers, providers, and site visits to identify the transitional care outcomes and service components that matter most to patients. In this first phase, based on this information and an extensive evidence-based review of the research literature, the ACHIEVE team will develop surveys to be administrated in Phase II. The project team will conduct mail and phone surveys of patients and caregivers recruited from approximately 45 hospitals across the U.S. to assess what transitional care services patients and caregivers experience and how they are associated with outcomes. Additionally, the project team will conduct healthcare provider surveys and site visits to assess the facilitators and barriers to implementing transitional care strategies, organizational contexts (leadership and physician engagement, change culture, etc.), and community collaboration.

Outcomes and Impact:

Through rigorous study and evaluation, Project ACHIEVE will:

  1. Identify best practices in care transitions that matter most to patients and their caregivers, and reduce excess emergency department and hospital utilization.
  2. Develop a toolkit to guide informed decisions and spread these best practices across the U.S.
  3. Develop Care Transitions Surveys that can standardize evaluation of patients' and caregivers' experience with care transitions.

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Study Type : Observational
Actual Enrollment : 7939 participants
Observational Model: Cohort
Time Perspective: Prospective
Official Title: Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Actual Study Start Date : March 2015
Actual Primary Completion Date : April 30, 2019
Actual Study Completion Date : June 30, 2019

Group/Cohort Intervention/treatment
Diverse, high-risk patient populations Behavioral: Patient Communication and Care Management

Received the following Transitional Care strategies:

  1. Helpful Health Care Contact OR Symptom Management
  2. Post-discharge Care Consultation
  3. Patient Goal/Preference Assessment
  4. Plain Language Communication in Hospital
  5. Plain Language Communication at Home
  6. Transition Summary for Patients and Family Caregivers

Behavioral: Home-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies:

  1. Transition Team
  2. Home visits
  3. Plain Language Communication at Home
  4. Promote Trust at Home
  5. Referral to Community Services
  6. Follow-up Appointment

Behavioral: Hospital-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies:

  1. Post-discharge care consultation
  2. Identify High-Risk Patients and Intervene
  3. Medication Reconciliation
  4. Plain Language Communication in Hospital
  5. Promote Trust in the Hospital
  6. Transition Summary for Patients and Family Caregivers

Behavioral: Patient/Caregiver Assessment and Provider Information Exchange

Received the following Transitional Care Strategies:

  1. Patient Goal/Preference Assessment
  2. Identify High-Risk Patients and Intervene
  3. Timely Exchange of Critical Patient Information among Providers
  4. Patient/Family Caregiver Transitional Care Needs Assessment

Behavioral: Assessment and Teach Back

Received the following Transitional Care Strategies:

  1. Post-discharge care consultation
  2. Language Assessment
  3. Teach Back for Information and Skills

Other: Standard of Care (Reference)
No specific Transitional Care Strategy




Primary Outcome Measures :
  1. Hospital Readmission [ Time Frame: 30 days post hospital discharge ]
    Readmission to the hospital within 30 days of discharge.

  2. Emergency Department (ED) Visit [ Time Frame: 30 days post hospital discharge ]
    Visit to the ED within 30 days of hospital discharge.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


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Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Sampling Method:   Probability Sample
Study Population
Project ACHIEVE will focus on Medicare fee-for-services beneficiaries and study diverse high risk patient populations, including those with: 1) multiple chronic conditions; 2) mental health issues; 3) rural area domicile; 4) limited English proficiency or low health literacy; 5) low socioeconomic status; 6) Medicare and Medicaid dual eligible; 7) disabled and younger than 65.
Criteria

Inclusion Criteria:

  • diverse high risk patient populations, including those with:

    1. multiple chronic conditions
    2. mental health issues
    3. rural area domicile
    4. limited English proficiency or low health literacy
    5. low socioeconomic status
    6. Medicare and Medicaid dual eligible
    7. disabled and younger than 65.

Exclusion Criteria:

  • children
  • non-Medicare patients
  • Under police custody
  • Under suicide watch
  • In-hospital death
  • Transferred (not discharged) to another acute care hospital
  • Discharged against medical advice
  • Admission for primary diagnosis of psychiatric conditions
  • Admission for rehabilitation
  • Admission for medical treatment of cancer

Information from the National Library of Medicine

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

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT02354482


Locations
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United States, Kentucky
UK Healthcare
Lexington, Kentucky, United States, 40536
Sponsors and Collaborators
Mark Williams
University of Pennsylvania
Boston Medical Center
Westat
Kaiser Permanente
Telligen, Inc.
University of Illinois at Chicago
Hospital Research & Education Trust, American Hospital Association
Joint Commission Resources
America's Essential Hospitals
Louisiana State University Health Sciences Center Shreveport
United Hospital Fund
Caregiver Action Network
National Association of Area Agencies on Aging
Investigators
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Principal Investigator: Mark V Williams, MD University of Kentucky
  Study Documents (Full-Text)

Documents provided by Mark Williams, University of Kentucky:
Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):
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Responsible Party: Mark Williams, Principal Investigator, University of Kentucky
ClinicalTrials.gov Identifier: NCT02354482    
Other Study ID Numbers: 3048112229
First Posted: February 3, 2015    Key Record Dates
Results First Posted: November 26, 2019
Last Update Posted: November 26, 2019
Last Verified: November 2019
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No

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Studies a U.S. FDA-regulated Drug Product: No
Studies a U.S. FDA-regulated Device Product: No