PATient Navigator to rEduce Readmissions

Summary

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

Conditions

• Chronic Obstructive Pulmonary Disease
• Heart Failure
• Sickle Cell Disease
• Myocardial Infarction
• Pneumonia

Interventions

BEHAVIORAL

Hospital usual care

Written discharge instructions provided to patients prior to hospital discharge.

BEHAVIORAL

Navigator intervention

A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team

BEHAVIORAL

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.

Sponsors & Collaborators

• Patient-Centered Outcomes Research Institute

  collaborator OTHER

• Society of Hospital Medicine

  collaborator OTHER

• COPD Foundation

  collaborator OTHER

• University of Kentucky

  collaborator OTHER

• Mended Hearts

  collaborator UNKNOWN

• American Heart Association

  collaborator OTHER

• Sickle Cell Disease Association of Illinois

  collaborator UNKNOWN

• AcademyHealth

  collaborator OTHER

• The National Association of Social Workers Foundation

  collaborator UNKNOWN

• Respiratory Health Association

  collaborator UNKNOWN

• University of Illinois Sickle Cell Patient Council

  collaborator UNKNOWN

• National Jewish Health

  collaborator OTHER

• Baystate Medical Center

  collaborator OTHER

• University of Illinois at Chicago

  lead OTHER

Principal Investigators

• Jerry A Krishnan, MD, PhD · University of Illinois at Chicago

• Elizabeth Calhoun, PhD · University of Arizona

• Mark V. Williams, MD · University of Kentucky

Study Design

Allocation

RANDOMIZED

Purpose

HEALTH_SERVICES_RESEARCH

Masking

SINGLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2014-07-31

Primary Completion

2016-10-31

Completion

2016-10-31

Countries

• United States

Study Locations