PATIENT-CENTERED TRANSITION (PaCT) PROJECT

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Ayan Hussein University of Georgia

Mentored by Shreya Kangovi, M.D

Improving the Transition from Hospital to Primary Care for Socioeconomically Vulnerable Patients

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How will I get to the pharmacy to get my prescriptions filled??

What clinic should I go to for my follow-up care??

Who will watch my children while I recover?

Where do I look for a primary doctor?

How do I sign up for health insurance?

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

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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

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Community Health Workers

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Tamala Carter Mary White Sharon McCollum

The Plan…The PaCT Project

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Hospital

Discharge

Patient Home

PCP Clinic

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.

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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

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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.

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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)

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I. Creating a Target List

Find eligible patients on “Canopy” and randomly pick a set of eligible patients to recruit.

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Enter each patient into RedCap with an assigned study ID #

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

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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 #

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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

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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

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14 Day Post Discharge Survey

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

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Dissemination Plans

1. Socioeconomically vulnerable patients of West/Southwest Philadelphia

2. Hospital-based Personnel

3. Community Health Center Personnel

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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

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The PaCT Team

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(From the left: Dan Ryan, Mary White, Tamala Carter, Dr. Shreya Kangovi and Ayan Hussein) *Sharon McCollum is missing in the group picture

Thank you!

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