Patient Readmission
Conditions
Keywords
Patient Readmission, Income
Brief summary
Unplanned 30-day hospital readmissions are an critical healthcare quality metric, with meaningful effects on patients and health systems operations. Interventions to reduce unplanned readmissions have primarily operated within a healthcare-centric frame, with enhancements to either pre- or post-discharge care planning, medication reconciliation, or visit frequency. Associations of 30-day readmission rates with poverty status and other social factors, however, suggest that attending to unmet social needs may yield added benefits to models focused on healthcare delivery. The purpose of the present trial is to provide evidence regarding the effects on 30-day readmissions of providing a one-time post-discharge income supplement to socially vulnerable older adults with medical complexity participating in an enhanced care coordination program.
Interventions
OTHERPost-discharge income supplement
$300 income supplement
Enhanced care planning provided by a nurse care manager
Sponsors
National Institute on Aging (NIA)
University of Southern California
AltaMed Health Services Corporation
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
PREVENTION
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
55 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* A participant in the underlying enhanced care planning program * aged 55 years or older * attending an outpatient clinic appointment as part of the underlying enhanced care planning program within 10 days of being discharged from an inpatient hospital stay * able to understand the study consent form (with interpretation services if needed)
Exclusion criteria
* The candidate is not discharged from the index admission to a community setting (e.g., they will be excluded if they are discharged to a skilled nursing facility) * The candidate has a legal guardian with control over financial decision-making * The candidate has been approached about the study during a previous encounter * The index hospitalization was a planned admission
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Unplanned 30-day readmission | Within 30 days of the index hospital discharge | Whether a participant has an unplanned readmission within 30 days of the index hospital discharge |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| 30-day post-discharge medical expenditures | Within 30 days of the index hospital discharge | Total medical expenditures in the 30 days after the index hospital discharge |
| 90-day post-discharge medical expenditures | Within 90 days of the index hospital discharge | Total medical expenditures in the 90 days after the index hospital discharge |
| 90-day post-discharge medical readmission OR emergency department visit | Within 90 days of the index hospital discharge | Whether a participant has an unplanned readmission OR emergency department visit within 90 days of the index hospital discharge |
| Unplanned 90-day readmission | Within 90 days of the index hospital discharge | Whether a participant has an unplanned readmission within 90 days of the index hospital discharge |
| 30-day post-discharge medical readmission OR emergency department visit | Within 30 days of the index hospital discharge | Whether a participant has an unplanned readmission OR emergency department visit within 30 days of the index hospital discharge |
Other
| Measure | Time frame | Description |
|---|---|---|
| Post-discharge care plan adherence | Within 90 days of the index hospital discharge | Clinic visit attendance, medication fills/refills |
Countries
United States
Outcome results
None listed