1 PATIENT-CENTERED TRANSITION (PaCT) PROJECTImproving the Transition from Hospital to Primary Care for Socioeconomically Vulnerable Patients Ayan Hussein University of Georgia Mentored by Shreya Kangovi, M.D
2 How do I sign How will I get to the up for health Who will watch pharmacy to get my insurance? my children prescriptions filled?? while I recover? Where do I lookWhat clinic for a primaryshould I go to for doctor?my follow-upcare??
3Recognizing the problem • Uninsured/Medicaid patients more likely than the privately insured to: • not adhere to discharge medications • lack timely primary care provider (PCP) follow-up • be readmitted to the hospital
4Project Overview• The Patient-Centered Transition (PaCT) Study is a clinical trial of a community-based intervention which is designed to enhance the transition from hospital to home for socioeconomically vulnerable patients.• Community Health Workers or PaCT Partners help patients who have been cared for at the University of Pennsylvania Hospital and Presbyterian Hospital with the transition from hospital to a primary care clinic
5Community Health WorkersTamala Carter Mary White Sharon McCollum
6The Plan…The PaCT Project Hospital Discharge Patient Home PCP Clinic
7Evaluating the Plan • Study Design: Randomized-Controlled Trial • Patient Population: ▫ Uninsured/Medicaid ▫ General Medicine ▫ Residents of 19104, 19131, 19139, 19143, 19146 ▫ 18-65 years old ▫ Discharged to home and advised to follow up with PCP • Study Time Period: the enrollment period is May 15th, 2011 to May 15th, 2012.
8Evaluating the Plan…Study Aims• Primary Aim: Our primary aim is to evaluate whether The PaCT Project is more effective than usual discharge planning at increasing rates of completion for recommended post-discharge follow-up care with a PCP
9Evaluating the Plan…Study Aims• Secondary Aims: To evaluate whether The PaCT Project is more effective than usual discharge planning at: ▫ Improving health attitudes and behaviors required for a successful post-hospital transition to primary care. ▫ Improving post-discharge outcomes: self-rated health, patient satisfaction and acute care re- utilization.
10Systematic Data Collection I. Creating a Target List for the day (Dan & Ayan) II. Enrolling patients(Dan and Ayan) III. Randomization of enrolled patients (Dr. Kangovi) IV. Intervention by trained Community Health Workers (CHWs) or PaCT partners (Mary and Sharon) V. 14 day follow-up survey (Dan and Ayan)
11I. Creating a Target List Find eligible patients on “Canopy” and randomly pick a set of eligible patients to recruit.Enter each patient into RedCap with an assigned study ID #
12II. Enrolling Patients Locate the patients in the hospital Obtain Informed Consent Alert Dr. Kangovi of enrolled patients as they occur Collect Contact Info and administer verbal baseline survey Give patient gift card and conclude visit
13III. Randomization of Enrolled Patients • PaCT group vs. Non-PaCT group • Research assistants are blinded • Whether or not a patient gets a community health worker depends on the his/her study ID #
14IV. Intervention by PaCT Partners • A trained Community Health Worker (CHW) meets the patients in the hospital before they are even discharged • Connect patient to services such as: Transportation Childcare Insurance Debt Collection Drug & Alcohol Counseling
15V. 14 day follow-up survey• Check Sunrise daily for patients’ discharge status• Call the patient two weeks after the discharge day• Make a home visit if we can’t reach the patient• Conduct a follow up survey• Mail the patient a gift card
1614 Day PostDischargeSurvey
17Statistical Analysis• Hypothesis testing: ▫ Primary Hypothesis: PaCT patients will have a higher proportion of follow up to PCP within 2 wks post discharge than patients in control group. 1. Patients did complete follow-up 2. Patients did not complete follow-up
18Dissemination Plans1. Socioeconomically vulnerable patients of West/Southwest Philadelphia2. Hospital-based Personnel3. Community Health Center Personnel
19Lessons Learned• Doing research can be fun!• Ask whenever in doubt!• It is important to share your findings with the community• The process of conducting a research study
20 The PaCT Team(From the left: Dan Ryan, Mary White, Tamala Carter, Dr. Shreya Kangovi and Ayan Hussein)*Sharon McCollum is missing in the group picture