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| ID | Type | Description | Link |
|---|---|---|---|
| A534270 | Other Identifier | UW Madison | |
| Protocol Version 12/23/25 | Other Identifier | UW Madison |
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The goal of this pragmatic clinical trial is to learn if it is possible to implement a Primary Hospital Provider (PHP) team that aims to improve continuity of care for patients who are frequently hospitalized. The main question it aims to answer is: Are patients assigned to the PHP team more likely to be assigned to this team during a follow up hospitalization? Researchers will compare this to similar patients assigned to receive usual care. Some patient participants (or their caregivers) from both the PHP team and usual care groups will be asked to participate in interviews to help researchers understand the needs of patients who are frequently admitted and the care they receive.
The overarching goal of this study is to reduce inpatient care fragmentation for high-need, high-complexity (HNHC) patients and improve outcomes by implementing a primary hospital provider (PHP) team. In this study, we will specifically evaluate the feasibility of implementation of this team as well as workforce and operational acceptance, as well as its impact on continuity of hospital medicine care across subsequent admissions.
The study is conducted as a two-arm, pragmatic hybrid type II effectiveness implementation trial with two sequential phases. Phase 1 focuses on initial feasibility and early acceptability of the PHP team. Phase 2 evaluates sustained implementation, reach, and longitudinal continuity outcomes using the same intervention, eligibility criteria, and study procedures. No changes will be made to the intervention, eligibility criteria, or data collection methods between phases.
Study Aims:
Aim 1 Primary Implementation Objective: Compare the fragmentation in hospital medicine care during subsequent admissions for HNHC patients assigned to the PHP team with those continuing to receive usual care.
Aim 2 Primary Exploratory Objective: Explore perceptions of care among HNHC patients and caregivers randomized to the PHP team and to a usual care team.
Aim 3 Secondary Exploratory Objective: Identify operational perceptions of the implementation of the PHP team from a workforce and system-level perspective.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| PHP Team | Experimental | PHP Team |
|
| Usual Care | No Intervention | Usual Care hospital medicine team |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Primary Hospital Provider Team | Other | The PHP team aims to enhance continuity during hospital readmissions with a consistent cohort of seven hospital medicine physicians and two advanced practice providers (APPs). To improve care transitions, the team will have an integrated case manager who will continue following PHP patients during subsequent hospitalizations. Physicians will follow a standard seven-day service schedule, with the two APPs alternating five-to-seven-day periods. Daily huddles between physicians and APPs will further promote continuity. During the index admission, the PHP team will create a care plan in consultation with the patient to improve standardization of inpatient care and transition to outpatient settings. Communication will be a core tenet of the team, with scheduled monthly team meetings of physicians, APPs, case manager, dyad partner, and representatives from nursing and therapy services to revise individualized care plans for PHP patients and brainstorm solutions for complex challenges. |
| Measure | Description | Time Frame |
|---|---|---|
| Number of patients readmitted to the PHP team | The number of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations. | Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months |
| Number of patients readmitted to usual care team | The number of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations. | Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months |
| Percentage of patients readmitted to the PHP team | The percentage of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations. | Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months |
| Percentage of patients readmitted to usual care team | The percentage of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations. | Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months |
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| Measure | Description | Time Frame |
|---|---|---|
| Themes that emerge as barriers from the patient and/or caregiver perspective | Qualitative barriers during hospitalization for high-need, high-complexity patients that emerge from patient and/or caregiver interviews. Interviews will be coded and themed and reported here. | 6 months |
| Themes that emerge as facilitators from the patient and/or caregiver perspective |
Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Sara Westergaard, MD, MPH | Contact | 608-261-1150 | swesterga@medicine.wisc.edu |
| Name | Affiliation | Role |
|---|---|---|
| Sara Westergaard, MD, MPH | University of Wisconsin, Madison | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| UW Hospital and Clinics | Recruiting | Madison | Wisconsin | 53792 | United States |
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Qualitative facilitators during hospitalization for high-need, high-complexity patients that emerge from patient and/or caregiver interviews. Interviews will be coded and themed and reported here. |
| 6 months |
| Acceptability as assessed from the patient and/or caregiver perspective | Acceptability of the intervention will be assessed from patient and/or caregiver interviews. Interviews will be coded and themed and reported here | 6 months |
| Themes that emerge as barriers from the hospitalist perspective | Qualitative barriers during hospitalization for high-need, high-complexity patients that emerge from focus groups with hospitalists. Focus groups will be coded and themed and reported here. | 4 months |
| Themes that emerge as facilitators from the hospitalist perspective | Qualitative facilitators during hospitalization for high-need, high-complexity patients that emerge from focus groups with hospitalists. Focus groups will be coded and themed and reported here. | 4 months |
| Acceptability as assessed from the hospitalist perspective | Acceptability of the intervention will be assessed from focus groups with hospitalists. Hospitalists will be coded and themed and reported here | 6 months |