None listed
Conditions
Brief summary
Hospitals face high levels of emergency presentations and demand for inpatient care particularly for Aboriginal Australian people from remote communities. Readmissions lead to overcrowded emergency departments and poorer patient outcomes. We will undertake a project to evaluate the efficacy of a multidimensional case-based management intervention in a regional Australian hospital with the aim of reducing hospital readmission and improving patient outcomes.
Interventions
Multi-dimensional case management approach
-Comprehensive assessment to identify factors driving readmission (e.g. housing, alcohol and other drugs, social and emotional well-being): This assessment will involve a face to face, semi structured interview with the patient lasting approximately 45-60 minutes.
-Coordination of early referral to inpatient, allied services and organization of outpatient services and equipment
-Patient and carer education including diagnosis, medication use, role and
Multi-dimensional case management approach -Comprehensive assessment to identify factors driving readmission (e.g. housing, alcohol and other drugs, social and emotional well-being): This assessment will involve a face to face, semi structured interview with the patient lasting approximately 45-60 minutes. -Coordination of early referral to inpatient, allied services and organization of outpatient services and equipment -Patient and carer education including diagnosis, medication use, role and access and follow-up plan: This will involve one face to face session focusing on diagnosis, a bedside session lasting 30-45mins with the team pharmacist focusing on medications and then a final session lasting 30mins with the team doctor or nurse focusing on discharge plan and follow-up -Primary health care liaison to ensure early review within 7 days post discharge Adherence to the intervention will be monitored by continued involvement with the program including engagement with the team during admissions, timely review with primary care and low drop out rate from the program.
Sponsors
Baker IDI Heart and Diabetes Institute
Study design
Allocation
Randomised controlled trial
Intervention model
Parallel
Primary purpose
Treatment
Masking
Open (masking not used)
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
4 or more adult medical/surgical admissions over the preceding 12 months OR more than 7 admissions over the past 24 months -A surgical admission is deemed appropriate if related to a patient's chronic disease eg. diabetic foot infections, chronic pancreatitis, cellulitis 2. Resident of Central Australia (including the cross border regions of Western Australia and South Australia and extending north to Elliot in the Northern Territory).
Exclusion criteria
1. Median life expectancy of 12 months or less based on independent specialist (including subspecialist physician) assessment 2. Stage 5 chronic kidney disease (eGFR < 15ml/min or receiving renal replacement therapy) 3. Solid organ transplant (including renal transplant) 4. Ongoing palliative care service review 5. Previous enrollment in the study (such subjects will have on-going care as per original study allocation)
Outcome results
None listed