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Enhanced Care Protocol for Patient Readmission

N/A
Waitlist Available
Led By Stephen N Davis, MBBS
Research Sponsored by University of Maryland, Baltimore
Eligibility Criteria Checklist
Specific guidelines that determine who can or cannot participate in a clinical trial
Must have
Patient is in Observation (and is expected to be admitted) or is admitted as an Inpatient Encounter. Consider eligible patients in any unit except Emergency Department.
Patient is at least 18 years of age.
Timeline
Screening 3 weeks
Treatment Varies
Follow Up 90 days post-hospital discharge
Awards & highlights

Study Summary

This trial aims to reduce unplanned hospital readmissions using a novel machine learning algorithm to identify high-risk patients and an enhanced transition care protocol.

Who is the study for?
This trial is for adults with a high risk of hospital readmission due to conditions like COPD, heart failure, diabetes, hypertension, or pneumonia. They must have a specific RecuR Score indicating their risk level and be fluent in English. Those already receiving home health care or not expected to return home post-discharge are excluded.Check my eligibility
What is being tested?
The study tests an enhanced transitional care plan against standard care for high-risk patients to prevent unplanned readmissions within 30 days after leaving the hospital. It uses AI (RecuR Score) to identify at-risk individuals who will receive extra support and education.See study design
What are the potential side effects?
Since this trial involves enhanced patient education and coordination of services rather than medication, traditional side effects are not applicable. However, there may be indirect effects related to changes in healthcare management.

Eligibility Criteria

Inclusion Criteria

You may be eligible if you check “Yes” for the criteria below
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I am currently admitted or expected to be admitted to the hospital, but not in the Emergency Department.
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I am 18 years old or older.
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My RecuR Score is high, or I was readmitted without being in a study before.

Timeline

Screening ~ 3 weeks
Treatment ~ Varies
Follow Up ~90 days post-hospital discharge
This trial's timeline: 3 weeks for screening, Varies for treatment, and 90 days post-hospital discharge for reporting.

Treatment Details

Study Objectives

Outcome measures can provide a clearer picture of what you can expect from a treatment.
Primary outcome measures
Number of moderate-high risk participants with 30-day post-discharge hospital readmission
Number of overall participants with 30-day post-discharge hospital readmission
Secondary outcome measures
30 day post-discharge mortality
30 day post-discharge unplanned hospital readmission
30-day post-discharge emergency department usage
+2 more

Trial Design

2Treatment groups
Experimental Treatment
Active Control
Group I: Arm 2: Receives Intervention "A" and Intervention "B"Experimental Treatment2 Interventions
Additional educational training using iPads. Education using iPad and/or teach-back components to reinforce the individualized disease and medication specific education. iPads are programmed with patient education from "The Patient Channel." This visit will be completed by a TNN. Focus on readmission risk during Care Transition Rounds. Multi-disciplinary team conducts daily rounds to discuss patient. TNNs share the risk scores for the patients and discuss coordination of the patient receiving interventions and other resources suggested by team members. Home health care from Home Health Services (HHS), Mobile Integrated Healthcare (MIH) or Resources, Education and Access to Community Health (REACH). Involves home visits to the patient, environmental assessments, and medication reconciliation from a home health nurse. Duration and specifications of home health care depend on the patient's needs. Participants will be assigned based on program eligibility and availability.
Group II: Arm 1: Intervention AActive Control1 Intervention
Diagnosis education includes verbal 1:1 patient education by the Transitional Nurse Navigator (TNN) and a folder with Epic printed education and other handouts specific to that disease process. Follow-up appointment scheduling assistance, including transportation to the follow-up appointment. The Community Health Worker (CHW) or TNN will schedule the appointments for the PCP and other specialists within 1 week when available. Offer resources in the community post the 1:1 meeting with the patient to meet specific access to care challenges identified for that patient by the TNN or CHW. Provide weekly follow-up calls for one month by TNN or delegate. Social Determinants of Health (SDOH) assessment. Screenings by CHW regarding patients' SDOH and documentation in the EHR (Epic) of this SDOH assessment. If a patient demonstrates a need, a CHW will help identify and offer opportunities for the patient.

Find a Location

Who is running the clinical trial?

University of Maryland, BaltimoreLead Sponsor
684 Previous Clinical Trials
373,109 Total Patients Enrolled
3 Trials studying Pneumonia
418 Patients Enrolled for Pneumonia
University of Maryland Medical SystemUNKNOWN
Stephen N Davis, MBBSPrincipal InvestigatorUniversity of Maryland, Baltimore
3 Previous Clinical Trials
88 Total Patients Enrolled

Media Library

Enhanced Care Clinical Trial Eligibility Overview. Trial Name: NCT05765903 — N/A
Pneumonia Research Study Groups: Arm 1: Intervention A, Arm 2: Receives Intervention "A" and Intervention "B"
Pneumonia Clinical Trial 2023: Enhanced Care Highlights & Side Effects. Trial Name: NCT05765903 — N/A
Enhanced Care 2023 Treatment Timeline for Medical Study. Trial Name: NCT05765903 — N/A

Frequently Asked Questions

These questions and answers are submitted by anonymous patients, and have not been verified by our internal team.

Could potential participants still join this experiment?

"Clinicaltrials.gov reveals that this research is not garnering any more patients - the trial was created on April 1st 2023 and last updated March 1st of the same year. However, 1834 other clinical trials are seeking volunteers at present time."

Answered by AI
~0 spots leftby Sep 2026