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| ID | Type | Description | Link |
|---|---|---|---|
| U54AG063546 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| National Institute on Aging (NIA) | NIH |
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The goal of this observational study is to learn the feasibility, acceptability, appropriateness, and adherence to a case management intervention. PartnerED is a case management intervention that aims to reduce unnecessary hospital admissions by providing real-time, structured information and discharge support to emergency department providers via phone and fax. The intervention is led by chronic care managers employed by Bluestone Accountable Care Organization, a physician group primarily serving patients in assisted living centers.
PartnerED is a case management intervention that aims to reduce unnecessary hospital admissions by providing real-time, structured information and discharge support to emergency department providers via phone and fax. The intervention is led by chronic care managers employed by Bluestone Accountable Care Organization, a physician group primarily serving patients in assisted living centers.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| All patients with eligible emergency department visits | Experimental | Eligible emergency department visits were identified using electronic admission, discharge, and transfer notifications |
|
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Structured case management | Behavioral | When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information. |
| Measure | Description | Time Frame |
|---|---|---|
| Percent of Eligible Emergency Department Visits With Completed Outreach | Percent of eligible emergency department visits in which a case manager provided structured clinical and discharge support information to a emergency department provider about a patient who was in their care, with the goal of avoiding an unnecessary hospitalization | Within 1-3 hours of emergency department registration |
| Measure | Description | Time Frame |
|---|---|---|
| Percent of Successful Outreach Conversations in Which Staff Reported Avoidance of an Unnecessary Hospitalization | Case manager self-report of whether she/he was successful in avoiding an unnecessary hospitalization of a patient after providing structured clinical and discharge support information to the emergency department provider | Within 24 hours of emergency department registration |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Ellen McCreedy, PhD, MPH | Brown University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Bluestone Accountable Care Organization | Omaha | Nebraska | 68154 | United States |
Data use agreements do not allow for sharing individual participant data
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| ID | Title | Description |
|---|---|---|
| FG000 | All Patients With Eligible Emergency Department Visits | Structured case management: When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | All Patients With Eligible Emergency Department Visits | Structured case management: When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Percent of Eligible Emergency Department Visits With Completed Outreach | Percent of eligible emergency department visits in which a case manager provided structured clinical and discharge support information to a emergency department provider about a patient who was in their care, with the goal of avoiding an unnecessary hospitalization | 1376 study participants had a total of 1989 emergency department visits. The unit of measure for this outcome is emergency department visits. | Posted | Count of Units | Emergency Department Visits | Within 1-3 hours of emergency department registration | Emergency Department Visits | Emergency Department Visits |
|
Adverse event data were collected during each participant's 4-month follow-up period.
Indicates deaths among eligible participants
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | All Patients With Eligible Emergency Department Visits | Structured case management: When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information. |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Ellen McCreedy | Brown University | (401) 863-7345 | ellen_mccreedy@brown.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP | Yes | Yes | No | Study Protocol and Statistical Analysis Plan | Sep 1, 2023 | Jul 1, 2025 | Prot_SAP_000.pdf |
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| ID | Term |
|---|---|
| D000544 | Alzheimer Disease |
| D004630 | Emergencies |
| ID | Term |
|---|---|
| D003704 | Dementia |
| D001927 | Brain Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
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|
| years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Race (NIH/OMB) | Count of Participants | Participants |
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| Ethnicity (NIH/OMB) | Count of Participants | Participants |
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| Region of Enrollment | Count of Participants | Participants |
|
| OG001 | Patients With Eligible Emergency Department Visits Without Dementia Diagnosis | Structured case management: When a Bluestone Accountable Care Organization registers in an emergency department, a Bluestone chronic care manager contacts emergency department clinicians by phone and fax to provide up-to-date clinical and discharge support information. |
|
|
| Secondary | Percent of Successful Outreach Conversations in Which Staff Reported Avoidance of an Unnecessary Hospitalization | Case manager self-report of whether she/he was successful in avoiding an unnecessary hospitalization of a patient after providing structured clinical and discharge support information to the emergency department provider | 705 study participants had a total of 851 emergency department visits with successful outreach conversations. The unit of measure for this outcome is emergency department visits. | Posted | Count of Units | EmergencyDepartmentVisits | Within 24 hours of emergency department registration | EmergencyDepartmentVisits | EmergencyDepartmentVisits |
|
|
|
| 3 |
| 1,376 |
| 0 |
| 1,376 |
| 0 |
| 1,376 |
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| D024801 |
| Tauopathies |
| D019636 | Neurodegenerative Diseases |
| D019965 | Neurocognitive Disorders |
| D001523 | Mental Disorders |
| D020969 | Disease Attributes |
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |