Impact of a Transitional Care Program on 30-Day Hospital... | NCT02421133

Status Module

Oversight Module

Description Module

Design Module

Interventional Study Design

Biospecimen

No data available

No data is available for this block.

Arms/Interventions Module

Arm Groups

Label	Type	Description	Intervention Names
Transitional care program.	Experimental	The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge.	Other: Transitional care program.
standard care program	Other	No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention).	Other: standard care program

Interventions

Name	Type	Description	Arm Group Labels	Other Names
Transitional care program.	Other	During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge. The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring. During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.

Outcomes Module

Primary Outcomes

Measure	Description	Time Frame
30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.	Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).	Within 30 days after hospital discharge.

Secondary Outcomes

Measure	Description	Time Frame
Length of stay in the short stay geriatric ward (index hospitalization)		Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days
Unscheduled hospital readmissions or emergency room visits		Within 30 and 90 days after the index hospital discharge.

Eligibility Module

Name	Affiliation	Role
Marc Bonnefoy	Centre Hospitalier Lyon Sud-Hospices Civils de Lyon	Principal Investigator

Facility	Status	City	State	ZIP	Country	Contacts
CH Gériatrique des Monts d'Or		Albigny-sur-Saône		69250	France
CH Bourg-en-Bresse

References Module

Citations

PubMed Identifier	Type	Citation	Retractions
26940678	Result	Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016 Mar 3;16:57. doi: 10.1186/s12877-016-0233-2.