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
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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.
Enter each patient into RedCap with an assigned study ID #
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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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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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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
(From the left: Dan Ryan, Mary White, Tamala Carter, Dr. Shreya Kangovi and Ayan Hussein)
*Sharon McCollum is missing in the group picture