PATient Navigator to rEduce Readmissions (PArTNER)

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

• Study Type: Interventional
• Study Design: Allocation: Randomized; Intervention Model: Parallel Assignment; Masking: Single (Outcomes Assessor); Primary Purpose: Health Services Research
• Conditions: Chronic Obstructive Pulmonary Disease; Heart Failure; Sickle Cell Disease; Myocardial Infarction; Pneumonia
• Interventions: Behavioral: Hospital usual care; Behavioral: Navigator intervention; Behavioral: Peer-led telephone support line
• Enrollment: 1029

Participant Flow

Recruitment Details
Pre-assignment Details

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Period Title: Overall Study
Started	511	518
Completed	378	368
Not Completed	133	150
Reason Not Completed
Lost to Follow-up	52	55
Death	12	12
Withdrawal by Subject	4	22
Other	65	61

Baseline Characteristics

Arm/Group Title		Usual Care	Usual Care + PArTNER	Total
Arm/Group Description		Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.	Total of all reporting groups
Overall Number of Baseline Participants		511	518	1029
Baseline Analysis Population Description		[Not Specified]
Age, Categorical; Measure Type: Count of Participants; Unit of measure: Participants
	Number Analyzed	511 participants	518 participants	1029 participants
	<=18 years	0 0.0%	0 0.0%	0 0.0%
	Between 18 and 65 years	412 80.6%	423 81.7%	835 81.1%
	>=65 years	99 19.4%	95 18.3%	194 18.9%
Age, Continuous; Mean (Standard Deviation); Unit of measure: Years
	Number Analyzed	511 participants	518 participants	1029 participants
		49.9 (17.0)	49.8 (16.5)	49.9 (16.8)
Sex: Female, Male; Measure Type: Count of Participants; Unit of measure: Participants
	Number Analyzed	511 participants	518 participants	1029 participants
	Female	290 56.8%	277 53.5%	567 55.1%
	Male	221 43.2%	241 46.5%	462 44.9%
Ethnicity (NIH/OMB); Measure Type: Count of Participants; Unit of measure: Participants
	Number Analyzed	511 participants	518 participants	1029 participants
	Hispanic or Latino	40 7.8%	49 9.5%	89 8.6%
	Not Hispanic or Latino	471 92.2%	468 90.3%	939 91.3%
	Unknown or Not Reported	0 0.0%	1 0.2%	1 0.1%
Race (NIH/OMB); Measure Type: Count of Participants; Unit of measure: Participants
	Number Analyzed	511 participants	518 participants	1029 participants
	American Indian or Alaska Native	1 0.2%	3 0.6%	4 0.4%
	Asian	4 0.8%	6 1.2%	10 1.0%
	Native Hawaiian or Other Pacific Islander	0 0.0%	0 0.0%	0 0.0%
	Black or African American	424 83.0%	423 81.7%	847 82.3%
	White	62 12.1%	72 13.9%	134 13.0%
	More than one race	7 1.4%	4 0.8%	11 1.1%
	Unknown or Not Reported	13 2.5%	10 1.9%	23 2.2%
Region of Enrollment; Measure Type: Number; Unit of measure: Participants
United States	Number Analyzed	511 participants	518 participants	1029 participants
		511	518	1029

Outcome Measures

1. Primary Outcome

Title	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	406	391
Mean (Standard Error); Unit of Measure: T-score
	-0.2 (0.5)	-1.7 (0.5)

2. Primary Outcome

Title	PROMIS Informational Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	405	391
Mean (Standard Error); Unit of Measure: T-score
	2.3 (0.6)	2.5 (0.6)

3. Secondary Outcome

Title	PROMIS Emotional Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	401	390
Mean (Standard Error); Unit of Measure: T-score
	-0.1 (0.5)	-0.1 (0.5)

4. Secondary Outcome

Title	PROMIS Instrumental Support (v2.0, SF4a)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	403	391
Mean (Standard Error); Unit of Measure: T-score
	1.0 (0.5)	0.6 (0.5)

5. Secondary Outcome

Title	PROMIS Global Health, Physical (v1.1, SF)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	408	389
Mean (Standard Error); Unit of Measure: T-score
	4.6 (0.4)	4.4 (0.4)

6. Secondary Outcome

Title	PROMIS Global Health, Mental (v1.1, SF)
Description	Change in T-score from baseline to 30 days post discharge (30 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	408	389
Mean (Standard Error); Unit of Measure: T-score
	0.8 (0.4)	0.6 (0.4)

7. Secondary Outcome

Title	PROMIS Emotional Distress-Anxiety (v1.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates improvement. A change equal to 0 indicates no change. A change >0 indicates worsening.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	375	365
Mean (Standard Error); Unit of Measure: T-score
	0.3 (0.6)	-1.1 (0.6)

8. Secondary Outcome

Title	PROMIS Informational Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	373	363
Mean (Standard Error); Unit of Measure: T-score
	1.7 (0.6)	2.0 (0.7)

9. Secondary Outcome

Title	PROMIS Emotional Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	372	363
Mean (Standard Error); Unit of Measure: T-score
	0.1 (0.5)	-0.2 (0.5)

10. Secondary Outcome

Title	PROMIS Instrumental Support (v2.0, SF4a)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	374	363
Mean (Standard Error); Unit of Measure: T-score
	0.8 (0.5)	1.0 (0.5)

11. Secondary Outcome

Title	PROMIS Global Health, Physical (v1.1, SF)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	372	365
Mean (Standard Error); Unit of Measure: T-score
	3.4 (0.5)	3.6 (0.4)

12. Secondary Outcome

Title	PROMIS Global Health, Mental (v1.1, SF)
Description	Change in T-score from baseline to 60 days post discharge (60 days minus baseline). A change in t-score <0 indicates worsening. A change equal to 0 indicates no change. A change >0 indicates improvement.
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	372	366
Mean (Standard Error); Unit of Measure: T-score
	-1.3 (0.5)	01.1 (0.4)

13. Secondary Outcome

Title	Death
Description	Caregiver-reported and confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	502	497
Measure Type: Count of Participants; Unit of Measure: Participants
	4 0.8%	7 1.4%

14. Secondary Outcome

Title	Death
Description	Caregiver-reported and confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	493	488
Measure Type: Count of Participants; Unit of Measure: Participants
	9 1.8%	9 1.8%

15. Secondary Outcome

Title	Re-hospitalization or Death
Description	Confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	503	495
Measure Type: Count of Participants; Unit of Measure: Participants
	100 19.9%	112 22.6%

16. Secondary Outcome

Title	Re-hospitalization or Death
Description	Confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

[Not Specified]

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	493	487
Measure Type: Count of Participants; Unit of Measure: Participants
	147 29.8%	159 32.6%

17. Secondary Outcome

Title	ED Visit, Re-hospitalization, or Death
Description	Confirmed by EHR review
Time Frame	30 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	503	495
Measure Type: Count of Participants; Unit of Measure: Participants
	156 31.0%	154 31.1%

18. Secondary Outcome

Title	ED Visit, Re-hospitalization, or Death
Description	Confirmed by EHR review
Time Frame	60 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	494	487
Measure Type: Count of Participants; Unit of Measure: Participants
	210 42.5%	216 44.4%

19. Secondary Outcome

Title	Outpatient Healthcare Visit
Description	Self-reported
Time Frame	14 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	405	388
Measure Type: Count of Participants; Unit of Measure: Participants
	137 33.8%	112 28.9%

20. Secondary Outcome

Title	Outpatient Healthcare Visit
Description	EHR-reported
Time Frame	14 days post discharge

Outcome Measure Data

Analysis Population Description

Due to missing data, the number of participants analyzed may be less than the numbers provided in the Participant Flow module.

Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description:	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
Overall Number of Participants Analyzed	511	507
Measure Type: Count of Participants; Unit of Measure: Participants
	236 46.2%	232 45.8%

Adverse Events

Time Frame	Adverse event data were collected from enrollment through 60 days after hospital discharge.
Adverse Event Reporting Description	[Not Specified]
Arm/Group Title	Usual Care	Usual Care + PArTNER
Arm/Group Description	Hospital usual care Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.	Navigator intervention: (Community health worker, peer-led telephone support line, usual care) Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge. Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.
All-Cause Mortality
	Usual Care	Usual Care + PArTNER
	Affected / at Risk (%)	Affected / at Risk (%)
Total	12/511 (2.35%)	12/518 (2.32%)
Serious Adverse Events
	Usual Care	Usual Care + PArTNER
	Affected / at Risk (%)	Affected / at Risk (%)
Total	12/511 (2.35%)	12/518 (2.32%)
General disorders
All-cause death * [1]	12/511 (2.35%)	12/518 (2.32%)
* Indicates events were collected by non-systematic assessment; [1] Causes of death were not collected.
Other (Not Including Serious) Adverse Events
Frequency Threshold for Reporting Other Adverse Events	5%
	Usual Care	Usual Care + PArTNER
	Affected / at Risk (%)	Affected / at Risk (%)
Total	0/511 (0.00%)	0/518 (0.00%)

Limitations and Caveats

No limitations or caveats to report.

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.

Results Point of Contact

• Name/Title: Jerry A. Krishnan, MD, PhD
• Organization: University of Illinois at Chicago
• Phone: 312-413-3291
• EMail: partner@uic.edu

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

LaBedz SL, Prieto-Centurion V, Mutso A, Basu S, Bracken NE, Calhoun EA, DiDomenico RJ, Joo M, Pickard AS, Pittendrigh B, Williams MV, Illendula S, Krishnan JA. Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study. J Gen Intern Med. 2022 Dec;37(16):4103-4111. doi: 10.1007/s11606-022-07461-0. Epub 2022 Mar 8.

• Responsible Party: Jerry Krishnan, University of Illinois at Chicago
• ClinicalTrials.gov Identifier: NCT02114515
• Other Study ID Numbers: PCORI-IH 1211-4365
• First Submitted: April 1, 2014
• First Posted: April 15, 2014
• Results First Submitted: October 20, 2017
• Results First Posted: February 15, 2019
• Last Update Posted: February 15, 2019