1. 1
PATIENT-CENTERED
TRANSITION (PaCT) PROJECT
Improving the Transition from Hospital to Primary Care for Socioeconomically
Vulnerable Patients
Ayan Hussein
University of Georgia
Mentored by Shreya Kangovi, M.D

2. 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 look
What clinic
for a primary
should I go to for
doctor?
my follow-up
care??

3. 3
Recognizing 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

4. 4
Project 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

5. 5
Community Health Workers
Tamala Carter Mary White Sharon McCollum

6. 6
The Plan…The PaCT Project
Hospital
Discharge
Patient Home
PCP Clinic

7. 7
Evaluating 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.

8. 8
Evaluating 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

9. 9
Evaluating 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.

10. 10
Systematic 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)

11. 11
I. 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 #

12. 12
II. 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

13. 13
III. 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 #

14. 14
IV. 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

15. 15
V. 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

16. 16
14 Day Post
Discharge
Survey

17. 17
Statistical 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

18. 18
Dissemination Plans
1. Socioeconomically vulnerable patients of
West/Southwest Philadelphia
2. Hospital-based Personnel
3. Community Health Center Personnel

19. 19
Lessons 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. 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

21. 21
Thank you!