Evaluation of the impact of a discharge coordinator on continuity of care from hospital to home

Status

Active, not recruiting

Phases

Unknown

Study type

Interventional

Source

ISRCTN

Registry ID

ISRCTN11113729

Enrollment

160

Registered

2006-03-01

Start date

2005-06-20

Completion date

Unknown

Last updated

2015-01-13

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Continuity of care from hospital to home Not Applicable

Interventions

Only patients who have been admitted as an in-patient with a diagnosis of acute coronary syndrome, congestive heart failure, pneumonia, exacerbation of chronic obstructive airways disease, falls, or c

Eligibility

Sex/Gender

All

Inclusion criteria

Inclusion criteria: Participants will be patients who: 1. Will be in hospital for more than 48 hours 2. Who are greater than 65 years of age 3. Who have a diagnosis of acute coronary syndrome, congestive heart failure, pneumonia, exacerbation of chronic obstructive airways disease, falls, or confusion Participants will also undergo a Short Portable Mental Status Questionnaire and must score above 5 out of 10 questions.

Exclusion criteria

Exclusion criteria: Patients will be excluded if they score less than 5 on the Short Portable Mental Status Questionnaire, or if they are transferred to another in-patient service at an acute care hospital

Design outcomes

Secondary

Measure	Time frame
Secondary outcomes include mortality and the proportion of patients readmitted to hospital (including admissions to the Emergency Department). Reasons for readmission will be assessed to determine if a medical error had an impact on readmission. Quality of life will be assessed using the 12-item Short Form health survey (SF-12) and patient satisfaction will be assessed using the Patient Satisfaction Questionnaire which includes items on convenience of care, access to care, continuity of care, competence, explanations of care, degree of consideration shown and overall satisfaction. Outcomes will be assessed at 4, 8, and 12 weeks after the intervention has been implemented.	—

Measure

Time frame

Secondary outcomes include mortality and the proportion of patients readmitted to hospital (including admissions to the Emergency Department). Reasons for readmission will be assessed to determine if a medical error had an impact on readmission. Quality of life will be assessed using the 12-item Short Form health survey (SF-12) and patient satisfaction will be assessed using the Patient Satisfaction Questionnaire which includes items on convenience of care, access to care, continuity of care, competence, explanations of care, degree of consideration shown and overall satisfaction. Outcomes will be assessed at 4, 8, and 12 weeks after the intervention has been implemented.

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Primary

Measure	Time frame
In this study, the primary outcome will be a composite endpoint to assess the level of discontinuity of care and will include: 1. The number of patients admitted with the target conditions who do not complete at least one recommended follow-up test 2. The number of patients admitted with the target conditions who do not attend at least one recommended follow-up appointment 3. The number of patients admitted with the target conditions who do not fill at least one medication prescribed at discharge	—

Measure

Time frame

In this study, the primary outcome will be a composite endpoint to assess the level of discontinuity of care and will include: 1. The number of patients admitted with the target conditions who do not complete at least one recommended follow-up test 2. The number of patients admitted with the target conditions who do not attend at least one recommended follow-up appointment 3. The number of patients admitted with the target conditions who do not fill at least one medication prescribed at discharge

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Countries

Canada

Outcome results

None listed

Source: ISRCTN (via WHO ICTRP) · Data processed: Feb 4, 2026