Status:
WITHDRAWN
The Impact of Post Discharge One-Time Home Visit: Bridging the Gap Between Hospital and Home.
Lead Sponsor:
Maimonides Medical Center
Conditions:
COPD
Coronary Artery Disease
Eligibility:
All Genders
65+ years
Brief Summary
A single post-hospital discharge home visit by a geriatric nurse practitioner or geriatric fellow can bridge the gap and ease the transition for elderly frail patients returning home after hospital ad...
Eligibility Criteria
Inclusion
- Patients admitted to the ACE unit during the study time frame, age 65 and over, and residing in the community before and after discharge from the hospital. Selected patients will have complex discharge plans including referrals to home care agencies, poly-pharmacy, multiple co-morbidities, history of repeated hospitalizations, and poor social support systems in the community. In addition, eligible patients will have at least one of eight admitting diagnoses, chosen for their high likelihood of requiring post-discharge home care needs. These diagnosis include: CHF, COPD, coronary artery disease, diabetes mellitus, stroke, hip fracture, peripheral vascular disease or cardiac arrhythmia. The GNP or fellow will then request permission from the patient's primary physician to do a one-time post-discharge home visit.
Exclusion
- Patients discharged to settings other than their homes (i.e. nursing home, sub-acute rehabilitation, etc.)Patients discharged to settings other than their homes (i.e. nursing home, sub-acute rehabilitation, etc.)
Key Trial Info
Start Date :
October 1 2006
Trial Type :
OBSERVATIONAL
Allocation :
ACTUAL
End Date :
Estimated Enrollment :
Patients enrolled
Trial Details
Trial ID
NCT00276367
Start Date
October 1 2006
Last Update
May 13 2015
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