THRIVE Intervention for Transition Care
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
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
Exclusion Criteria
Timeline
Screening
Participants are screened for eligibility to participate in the trial
Training
Case managers are trained on the THRIVE clinical pathway
Intervention
Participants receive intensive post-discharge case management and care coordination
Follow-up
Participants are monitored for readmissions, ED visits, and primary care or specialist visits
Treatment Details
Interventions
- THRIVE Intervention
Find a Clinic Near You
Who Is Running the Clinical Trial?
University of Pennsylvania
Lead Sponsor
Rita & Alex Hillman Foundation
Collaborator