Adult patients discharged from hospital at high risk of readmission Other
Conditions
Interventions
This is a single-centre pragmatic randomized controlled trial with three study arms, and the primary objective is to examine the effectiveness of a post-discharge call on 30-day ED visits. Participant
Sponsors
Fraser Health
Eligibility
Sex/Gender
All
Age
18 Years to No maximum
Inclusion criteria
Inclusion criteria: 1. Adult patients >18 years old with LACE score >9 (note, LACE scores <9 were included if patients were 45 or older) 2. Discharged to home, or assisted living 3. Discharged form hospital inpatient care within Fraser Health region
Exclusion criteria
Exclusion criteria: 1. Active home health patient 2. Discharged from inpatient psychiatric unit 3. Active community respiratory services patient 4. Seen in follow-up before the post-discharge call 5. Readmitted or in the ED before the post-discharge call 6. Received a call from their primary care provider or other registered nurse 7. Deceased 8. Discharged to hospice 9. Received nursing support from another service 10. Unable to receive the post-discharge call from FHVC
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| ED visits, defined as any visit in which a participant registered in any of the 12 EDs within the Fraser Health region, regardless of whether they were ultimately seen by a clinician, measured using data collected from across Fraser Health hospitals at one timepoint | — |
Secondary
| Measure | Time frame |
|---|---|
| The following secondary outcome measures were assessed at 7 and 30 days following the post-discharge call for the intervention group: 1. Hospital readmissions, defined as any admission to a hospital post-discharge, measured using data collected from across Fraser Health hospitals 2. Participant experience, measured using data collected through a survey developed by the research team | — |
Countries
Canada
Contacts
Public ContactMegan MacPherson
Outcome results
None listed