267 Participants Needed

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)

Trial Summary

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 data supports the effectiveness of the THRIVE Intervention treatment?

The THRIVE Intervention may be supported by research on similar treatments, such as nursing case management and specialist health visitor interventions, which have shown positive outcomes in managing conditions like failure to thrive in children and older adults. These approaches often involve coordinated care and personalized support, which can improve health outcomes.12345

How does the THRIVE Intervention treatment differ from other treatments for transition care?

The THRIVE Intervention is unique because it combines antenatal and early postnatal support to improve mental health, mother-infant bonding, and child development, specifically targeting pregnant women with complex health and social care needs. This approach is distinct from standard transition care treatments, which often focus on direct hand-over care or transition clinics without the same emphasis on early intervention and comprehensive support.56789

What is the purpose of this trial?

The goal of this stepped wedge pragmatic trial is to compare referral patterns and post discharge outcomes in Medicaid insured individuals discharge following a hospitalization\]. The aims are to 1) evaluate the implementation of the THRIVE clinical pathway, including feasibility, appropriateness, and acceptability and 2) examine referral patterns, 30- day readmission and Emergency Department (ED) utilization patterns for participants who receive THRIVE support services. During hospitalization participants will receive a referral to home care services and will be seen by a home care nurse within 48 hours following discharge. A discharging physician or Advanced Practice Provider will maintain clinical oversight for 30 days or until the patient sees primary care provider or specialist. A Care Coordination Team conducts weekly case conferences to ensure social and health needs are being addressed for 30 days post-discharge. Researchers will compare Medicaid insured patients discharged during the study, to those receiving usual care to determine if there are differences in post-acute utilization outcomes.

Research Team

MB

Margo B Brooks Carthon, PhD RN

Principal Investigator

University of Pennsylvania

Eligibility Criteria

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

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

Treatment Details

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.
Participant Groups
2Treatment groups
Experimental Treatment
Active Control
Group I: THRIVE InterventionExperimental Treatment1 Intervention
1 month intensive post discharge case management and care coordination.
Group II: Usual CareActive Control1 Intervention
Discharge to home without intensive post acute case management or care coordination.

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+

Findings from Research

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]

References

Home enteral nutrition NICE guidelines and nutrition support in primary care. [2010]
Nursing case management for children with failure to thrive. [2004]
The diagnosis "failure to thrive" and its impact on the care of hospitalized older adults: a matched case-control study. [2023]
Geriatric failure to thrive. [2013]
A randomised controlled trial of specialist health visitor intervention for failure to thrive. [2019]
Controlled evaluation of a transition clinic for Dutch young people with cystic fibrosis. [2021]
A realist process evaluation of Enhanced Triple P for Baby and Mellow Bumps, within a Trial of Healthy Relationship Initiatives for the Very Early years (THRIVE): study protocol for a randomized controlled trial. [2021]
A Review of Interventions Aimed at Facilitating Successful Transition Planning and Transfer to Adult Care Among Youth with Chronic Illness. [2017]
Team management of failure to thrive. [2009]
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