Chronic Diseases
Conditions
Keywords
readmission, care transition
Brief summary
To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH
Detailed description
Hospital with high readmission rate is view as having lower quality of care High readmission rate is view as wasteful healthcare spending Primary Aim: To find out if a transitional care model can reduce the rate of unscheduled readmission to the Department of Internal Medicine (DIM) in SGH A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Secondary Aim: To find out if a transitional care model can reduce the number of visits to the emergency department in SGH To find out the quality of our transitional care model by using a care transition measure (CTM-15)
Interventions
OTHERa transitional care model
Intervention extend from transfer of care to the study team from the initial admission medical team through 90 days after discharge Intervention in hospital includes the following. Comprehensive discharge planning based on the 6 principles. Discharge planning initially within 24 hours of recruitment Daily ward review of patients Weekly multi-disciplinary meeting Consolidation of medication and follow-up appointment before discharge Assessment of needs before discharge Comprehensive discharge summary and medication record at discharge Intervention after discharge: Work done mainly by integrated care nurse Review of patients within 48 hours after discharge via home visit or phone call Subsequent home visit as needed based on patient's needs At least weekly contact with pt or caregiver via telephone Telephone availability working weekday 8 AM to 5 PM Multi-disciplinary meeting for problematic cases Use chronic disease pathway for suitable patients
OTHERControl
Patients receive usual standard of care from the internal medicine team
Sponsors
Agency for Integrated Care, Singapore
Duke-NUS Graduate Medical School
Singapore General Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
HEALTH_SERVICES_RESEARCH
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
21 Years to No maximum
Healthy volunteers
No
Inclusion criteria
-More than 1 admission in the last 90 days
Exclusion criteria
* Subject is a non-resident * Subject has no local home address * Subject is from a long-term care facility during index admission * Subject is unable to participate in telephone surveillance * Subject is discharged before takeover * Subject has impaired decision making capacity without surrogate decision maker * Subject is pending or currently in critical care unit * Subject or caregiver is mentally unstable * Subject is haemodynamically unstable * Subject requires acute inpatient respiratory support * Subject requires acute inpatient dialysis support * Subject pending surgical intervention * Subject pending transfer to other specialist discipline * Primary team consultant declined to participate in this research
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Readmission rate | 30 days after index discharge | A readmission episode is defined as an episode of readmission to any tertiary hospital within 30 days after index discharge from SGH Readmission rate is calculated by dividing the total number of admission by the total number of patients |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Readmission rate | up to 180 days after index discharge | Readmission rate is calculated by dividing the total number of admission by the total number of patients. This will measured at 7 days, 90 days and 180 days of discharge |
| Quality of transitional care using a validated care transition measure (CTM-15) tool | 90 days after index discharge | Care transition measure survey of subjects |
| Emergency department attendance rate | Up to 180 days after index discharge | Emergency department attendance rate is calculated by dividing the total number of emergency department visits by the total number of patients. This will measured at 7 days, 30 days, 90 days and 180 days of discharge |
| Time to first readmission | Up to 90 days after index discharge | Censored time to readmission for both intervention and control group |
| Specialist Outpatient Clinic visits | Up to 180 days after index discharge | Outpatient clinic visit rate is calculated by dividing the total number of outpatient clinic visits by the total number of patients. This will measured at 90 days and 180 days of discharge |
Countries
Singapore
Outcome results
None listed