Tailoring Post Discharge (TPD) - Bridging the Gap Through Education and Community Support

Status: Recruiting
Location: See location...
Intervention Type: Other
Study Type: Interventional
Study Phase: Not Applicable
SUMMARY

This randomized control trial seeks to better understand the educational needs of Acute Coronary Symptom (ACS) patients including the optimal timing and method of delivery as well as linkages with appropriate community resources and supports are important for cardiac patients to self-manage post hospital discharge to improve outcomes. While there is some literature of the learning needs of ACS patients, there is a paucity of research related to the timing and preferred methods of delivery. This study aims to better understand how best to tailor care for ACS patients from hospital to community. Specifically, the investigators propose a 2 phased approach to understand the needs of patients, and then to develop and deliver a tailored approach to assess, educate and support patients both in-hospital and within the community. The intervention compares 1) a virtual remote home monitoring (RHM) platform and 2) Rapid Response Nursing (RRN) staff to follow, educate and support ACS patients post hospital discharge for a period of no more than 30 days. The Primary Objective of this study is to safely transition low risk ACS patients, from hospital to home, with appropriate supports to safely self-manage in the community and to provide educational and community supports to improve post discharge outcomes of low risk ACS patients

Eligibility
Participation Requirements
Sex: All
Minimum Age: 18
Maximum Age: 80
Healthy Volunteers: f
View:

• All adult patients who presented with ACS to St. Boniface Hospital

• Considered low risk based on cardiac risk, comorbidities, community and patient resources

Locations
Other Locations
Canada
St. Boniface Hospital
RECRUITING
Winnipeg
Contact Information
Primary
Shuangbo Liu, MD
sliu@sbgh.mb.ca
2042581266
Backup
David Kent, MSc
dkent@sbgh.mb.ca
2042372985
Time Frame
Start Date: 2023-02-15
Estimated Completion Date: 2025-07-30
Participants
Target number of participants: 200
Treatments
Experimental: Remote Home Monitoring (RHM)
Remote Home Monitoring Platform (RHM): will be utilized to help tailor education and support for the patient after they have been discharged from the hospital. The platform will provide access to and delivery of health related education and information for continued self-care within the community. The platform will be used to evaluate post discharge symptoms and for health care providers to access the need for continued direct patient care and education through virtual processes.
Active_comparator: Rapid Response Nursing (RRN)
Rapid Response Nursing Team (RRN): The RRN will help clients/patients to:~* Understand their current health conditions, treatments, how to manage symptoms and when/who to ask for help; Specifically; they will~* Help clients to understand their hospital discharge plan;~* Support patients during their recovery at home;~* Reinforce and contribute to in-hospital education about heath health and recovering safely at home;~* Review medications to help clients understand the purpose, side effects and how to take prescribed medications correctly, including assisting clients with getting prescriptions filled;~* Connect with their Home Clinic, ensuring everyone has the necessary information for follow-up care;~* Connect clients with a Home Clinic if they do not have one; and~* Access appropriate home supports to help clients remain at home safely for as long as possible.
No_intervention: Registry
Registry Arm:~Patients who fit the criteria for study inclusion and choose not to participate in the main study will be provided with an opportunity to consent to the registry arm of the study. The registry arm of the study is an opportunity to establish a standard of care group free from research bias. Patients who enroll in the registry will only need to complete a short questionnaire before they are discharged home which will take approximately 5 minutes. Additionally, research staff will also complete a medical chart review to identify specific medical information related to their demographics, cardiac procedure, hospital stay, recovery, and to identify any re-admissions to hospital that may have occurred after the patient has been discharged home.
Related Therapeutic Areas
Sponsors
Leads: St. Boniface Hospital

This content was sourced from clinicaltrials.gov