Summary

for people ages 18-120 (full criteria)
study started
estimated completion
Oanh K Nguyen

Description

Summary

The investigators will conduct a feasibility study of an enhanced transitional care intervention, that will: 1) automate identification and risk-stratification of patients with CHF and IHD with social vulnerabilities; 2) incorporate a new standardized social vulnerabilities screening tool into clinical care; 3) enable electronic referrals to community resources; and 4) add novel community-based interventions to the existing medically-oriented transitional care intervention that is the standard of care at the study hospital (Parkland Hospital in Dallas, Texas) and other hospitals nationwide.

Official Title

Addressing Social Vulnerabilities to Prevent Hospital Readmissions in Adults With Cardiovascular Disease

Details

The investigators plan to develop, pilot and evaluate the feasibility of an existing medically oriented transitional care intervention enhanced to also address social vulnerabilities, to prevent readmissions in congestive heart failure (CHF) & ischemic heart disease (IHD). The intervention design will be based on the Andersen Behavior Model of Health Services Use, highlighting pathways for clinical linkages to community resources to facilitate individual behavior change. To summarize, although existing interventions have largely focused on individual- and health system-level factors such as optimizing medication regimens, discharge education, and post-discharge follow-up, much of the risk for readmission in patients with CHF and IHD is also driven by social vulnerabilities that are currently not addressed in medical settings. Community-based organizations are a valuable but untapped resource to ameliorate key social vulnerabilities (i.e., food/housing insecurity, behavioral health needs) that are major barriers to effective medication and visit adherence, self-management and lifestyle modification in patients with heart disease. Thus, the investigators propose an enhanced transitional care intervention that uses the Dallas Information Exchange Portal, a health information technology platform, to link patients to local community organizations at discharge. Addressing social vulnerabilities to enable better adherence, self-management, and lifestyle behaviors can in turn prevent readmissions and improve downstream health outcomes. The investigators will conduct a feasibility study of an enhanced transitional care intervention, that will: 1) automate identification and risk-stratification of patients with CHF and IHD with social vulnerabilities; 2) incorporate a new standardized social vulnerabilities screening tool into clinical care; 3) enable electronic referrals to community resources; and 4) add novel community-based interventions to the existing medically-oriented transitional care intervention that is the standard of care at Parkland and other hospitals nationwide. The investigators will assess feasibility and acceptability of our intervention using measures derived from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) implementation science framework.

Keywords

Congestive Heart Failure Ischemic Heart Disease Acute Myocardial Infarction Coronary Artery Disease Heart Failure Infarction Cardiovascular Diseases Myocardial Ischemia Coronary Disease Heart Diseases Myocardial Infarction Socially Enhanced Transitional Care Intervention

Eligibility

You can join if…

Open to people ages 18-120

  • patients hospitalized with CHF and IHD at high-risk for readmission

You CAN'T join if...

  • none

Lead Scientist

  • Oanh K Nguyen
    Dr. Nguyen’s research is focused on understanding and optimizing hospital care in safety-net settings and developing pragmatic approaches to addressing social determinants of health, particularly on the development and evaluation of transitional care strategies that address social vulnerabilities among individuals with complex medical needs.

Details

Status
not yet accepting patients
Start Date
Completion Date
(estimated)
Sponsor
University of California, San Francisco
ID
NCT03613064
Study Type
Interventional
Last Updated