THRIVE Intervention for Transition Care

MB
HB
Overseen ByHeather Brom, PhD, RN
Age: 18+
Sex: Any
Trial Phase: Academic
Sponsor: University of Pennsylvania
No Placebo GroupAll trial participants will receive the active study treatment (no placebo)

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests a new method to assist Medicaid patients after hospital discharge. It ensures they receive proper home care and avoid returning to the hospital or emergency room shortly after discharge. The trial compares two groups: one receives special support and care coordination (THRIVE Intervention) for 30 days, while the other receives standard care without additional help. It suits Pennsylvania residents with Medicaid who were recently hospitalized and agree to home care services. As an unphased trial, this study provides a unique opportunity to enhance post-hospital care for Medicaid patients.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications.

What prior data suggests that the THRIVE Intervention is safe for post-discharge care?

Research has shown that the THRIVE program is generally safe for patients. Studies have found that participants receiving THRIVE support had fewer hospital and emergency room visits, indicating the program is well-tolerated. These studies reported no serious side effects. Instead, patients benefited from the extra care and attention after hospital discharge. The THRIVE program focuses on helping people manage their care at home, an approach that has been shown to help maintain health after leaving the hospital. The program primarily involves regular check-ins and coordination with healthcare providers, emphasizing improved support rather than new medications, which is typically safe.12345

Why are researchers excited about this trial?

Researchers are excited about the THRIVE Intervention because it offers a new approach to managing patient care after hospital discharge. Unlike the usual care, which often leaves patients to navigate their recovery alone, THRIVE provides intensive case management and care coordination for a month. This proactive support aims to reduce readmissions and improve recovery outcomes by ensuring that patients have the resources and guidance they need during the critical transition period from hospital to home.

What evidence suggests that the THRIVE Intervention is effective for improving post-discharge outcomes?

Research has shown that programs like the THRIVE Intervention, which participants in this trial may receive, can aid recovery after hospital discharge. Studies have found that these programs can reduce the likelihood of hospital readmission and enhance health post-discharge. For instance, patients receiving this care often report a better quality of life and fewer health issues. By coordinating care and providing follow-up, as seen in the THRIVE model, both social and health needs are addressed, leading to greater patient satisfaction. Although the strength of the evidence varies, these programs generally help patients transition from hospital to home.15678

Who Is on the Research Team?

MB

Margo B Brooks Carthon, PhD RN

Principal Investigator

University of Pennsylvania

Are You a Good Fit for This Trial?

This trial is for adults with Medicaid insurance in Pennsylvania who have been hospitalized and agree to home care. It's not for anyone under 18. The study looks at how well they do after leaving the hospital when they get extra support.

Inclusion Criteria

Residing in the state of Pennsylvania
Experienced a hospitalization at study hospital
I agree to receive care at a partner home care setting.
See 1 more

Exclusion Criteria

I am under 18 years old.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Training

Case managers are trained on the THRIVE clinical pathway

2 months

Intervention

Participants receive intensive post-discharge case management and care coordination

1 month
Weekly case conferences

Follow-up

Participants are monitored for readmissions, ED visits, and primary care or specialist visits

30 days

What Are the Treatments Tested in This Trial?

Interventions

  • THRIVE Intervention
Trial Overview The THRIVE intervention is being tested, which includes a referral to home care services within 48 hours of discharge, oversight by a physician or provider for 30 days, and weekly case conferences to address health and social needs.
How Is the Trial Designed?
2Treatment groups
Experimental Treatment
Active Control
Group I: THRIVE InterventionExperimental Treatment1 Intervention
Group II: Usual CareActive Control1 Intervention

Find a Clinic Near You

Who Is Running the Clinical Trial?

University of Pennsylvania

Lead Sponsor

Trials
2,118
Recruited
45,270,000+

Rita & Alex Hillman Foundation

Collaborator

Trials
3
Recruited
340+

Published Research Related to This Trial

Transition coordinators can significantly improve the transfer of youth with chronic illnesses to adult care by meeting with patients before the transfer, supporting them during the transition, and helping them keep appointments.
Establishing trusting relationships with adult providers and having discussions about the transition process with both pediatric and adult providers are crucial for successful care transfer, highlighting the importance of planning and communication in these interventions.
A Review of Interventions Aimed at Facilitating Successful Transition Planning and Transfer to Adult Care Among Youth with Chronic Illness.Weissberg-Benchell, J., Shapiro, JB.[2017]
A multidisciplinary team approach is essential for effectively treating failure to thrive in infants and young children, as it allows for a comprehensive evaluation of nutritional, medical, and psychosocial factors.
Nutritional management focuses on continuous assessment of growth, ensuring adequate energy and protein intake for catch-up growth, and providing personalized nutrition guidance, with long-term follow-up to adapt plans as the child grows.
Team management of failure to thrive.Peterson, KE., Washington, J., Rathbun, JM.[2009]

Citations

Pre-Implementation Strategies to Support Adaptation of ThriveThe goal of this paper is to describe the pre-implementation processes used by our team to adapt the Thrive care model to meet the transitional ...
Integrated Care Components in Transitional Care Models ...Service outcomes are more frequently reported compared to patient and provider outcomes, as out of the ten most frequent reported outcomes, ...
Effectiveness of transitional care interventions in patients with ...Transitional care interventions can improve quality of life and symptoms, although based on low or very low certainty of evidence.
Transitional Care Interventions in Improving Patient and ...This study aims to map existing evidence on effectiveness of transitional care interventions in improving post-discharge outcomes.
Effectiveness of Transitional Interventions in Improving ...We aimed to assess the effectiveness of transitional interventions with predischarge and postdischarge components in reducing readmissions and improving health ...
6.thrive-care.orgthrive-care.org/impact/
Our ImpactOur published study in BMJ Open Quality found that participants enrolled in Thrive experienced lower rates of rehospitalizations and Emergency Department. View ...
Transitional Care Support for Medicaid-Insured Patients ...This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric ...
Postpartum Discharge Transition | AIMThe Postpartum Discharge Transition Patient Safety Bundle was revised in 2021 to incorporate respectful care concepts and data collection tools.
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