A Pilot Randomized Trial of a Comprehensive Transitional Care Program for Colorectal Cancer Patients

Summary

The primary hypothesis is that a comprehensive transitional care program based on the premise of a patient-centered medical home versus routine care reduces emergency room visits and hospital readmissions without increasing costs among cancer patients undergoing surgery at a large safety-net hospital.

Conditions

• Colorectal Cancer
• Comprehensive Transitional Care Program

Interventions

OTHER

Patient education: One-on-one visit

The navigator or surgeon will have a one-on-one visit with he patient to answer any questions.

OTHER

Discharge planning: Assessment of barriers to discharge

Case management will be consulted on the day of surgery. The navigator will perform an assessment of barriers to discharge based on one-on-one interviews with the patient.

OTHER

Medication reconciliation: Patient medication review

The navigator will review the patient's medications with him/her prior to discharge.

OTHER

Appointment before discharge: Additional measure to ensure awareness of next clinic visit

Additional measures to ensure that patients are aware of the date, time, and place of their clinic visit(s) may include a phone calls or text messages to patients and their caregivers by the navigator, surgeon or clinic nurse.

OTHER

Transition coach

The navigator will assist with coordination of care and tracking follow-up appointments and tests.

OTHER

Patient-centered discharge instructions: Enhanced

Enhanced, language-specific, discharge instructions will be developed and provided to all patients verbally and in a written format designed for patients with limited literacy skills.

OTHER

Provider continuity: Specific surgeons responsible for coordinating care with medical/radiation oncology

Drs. Stefanos Millas (colorectal surgery) and Curtis Wray (surgical oncology) will be responsible for coordinating care with medical and radiation oncology as well as consulting when patients are readmitted to the hospital (if not admitted to the surgical service). Changes will be made to the clinic scheduling process for colorectal cancer surgery patients to minimize wait times, to allow them to be seen on a "walk-in" basis, and to prioritize visits for patients with urgent problems as identified by follow-up calls or inquiries to the Ask My Nurse hotline.

OTHER

Timely follow-up: Barriers to clinic follow-up visits will be discussed

Patients will be queried about financial barriers to clinic follow-up such as lack of money for parking and/or lack of transportation; parking vouchers and taxi/bus vouchers may be provided.

OTHER

Timely PCP communication

The operating surgeon will phone the PCP prior to and upon discharge to discuss concerns and follow-up care plans. Communication via the electronic medical record (EPIC) will also be sent. If the patient does not have a PCP, a referral will be made prior at the initial clinic visit and one provided.

OTHER

Follow-up telephone call

Patients will be contacted by phone by the navigator or surgeon on post-discharge day 1 to identify and address any concerns. If there are concerns, calls may be made on subsequent post-operative days.

OTHER

Patient hotline: 24 hour follow-up following call to Ask My Nurse number

Follow-up will occur within 24 hours of calling the Ask My Nurse number. Patients with emergent problems will be seen immediately by the surgical oncology team if available or the on call surgery team. Patients with non-urgent matters will be called by a member of the surgical oncology team. Arrangements will be made to see the patient in clinic or the ER within the next 8-16 hours depending upon severity and time of day.

Sponsors & Collaborators

• The University of Texas Health Science Center, Houston

  lead OTHER

Principal Investigators

• Lillian S Kao, MD, MS · The University of Texas Health Science Center, Houston

Study Design

Allocation

RANDOMIZED

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2015-02-28

Primary Completion

2016-02-29

Countries

• United States

Study Locations