Acute Disease
Conditions
Brief summary
The purpose of this study is to see whether a Virtual Ward reduces readmissions after hospital discharge.
Detailed description
We will conduct a pragmatic, randomized controlled trial to evaluate a new model of care for high-risk medical patients after discharge from hospital. This new model of care has two key elements. First, we will use the LACE index (see citation below for details) to identify patients who are at high risk of readmission or death after hospital discharge. These patients will be randomized to either the Virtual Ward or usual care on the day of discharge. Although patients being cared for in the Virtual Ward will reside at home, they will benefit from a hospital-like interdisciplinary team, a shared set of notes, a single point of contact, round-the-clock physician availability and increased co-ordination of specialist, primary and home-based community care for several weeks after hospital discharge.
Interventions
OTHERVirtual Ward
A multidisciplinary team to optimize medical and social care for patients residing in their own homes
OTHERUsual care
The usual care provided to patients after discharge from hospital
Sponsors
Canadian Institutes of Health Research (CIHR)
Toronto Central Local Health Integration Network
Ontario Ministry of Health and Long Term Care
Toronto Central Community Care Access Centre
Women's College Hospital
University Health Network, Toronto
Sunnybrook Health Sciences Centre
Unity Health Toronto
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Discharge from medical service * LACE score greater than or equal to 10 * Age greater than or equal or 18 * Resident in Toronto Central Local Health Integration Network catchment area * Patient or designate able to speak English well enough for follow up telephone calls
Exclusion criteria
* Previously enrolled in study * Discharged to a rehabilitation or complex continuing care facility
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Composite of readmission to hospital or death. | 30 days after hospital discharge | A binary outcome variable for each patient, representing either readmission to hospital or death within 30 days of hospital discharge. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Emergency department visits | 30 days after discharge | A binary outcome variable for each patient, representing an emergency department visit within the time periods noted above. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
| Long-term care admission | 30 days after discharge | A binary outcome variable for each patient, representing a long-term care admission within the time periods noted above. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
| Composite of readmission or death | 90 days after discharge | A binary outcome variable for each patient, representing either readmission to hospital or death within the time periods noted above. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
| Composite of readmission to hospital or death. | One year after discharge | Time to the composite outcome of either readmission to hospital or death. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Data will be censored on the date of the last follow up (i.e., 30 days, 90 days or 6 months). Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
| Readmission | One year after discharge | Time to readmission to hospital. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Data will be censored on the date of the last follow up (i.e., 30 days, 90 days or 6 months), or on death. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences. |
| Death | 90 days after discharge | A binary outcome variable for each patient, representing death within the time periods noted above. A research assistant blinded to the assignment will ascertain this information via telephone using a standardized script. Second, we may also ascertain this information by linking the data we collect to administrative databases housed at the Institute for Clinical Evaluative Sciences |
Countries
Canada
Outcome results
None listed