Implementation and Evaluation of A Health Innovation to Support Medicaid-Insured Individuals Following Hospitalization

Conditions

• Care Transitions

Eligibility Criteria

Sex

ALL

Age

18 Years - 99 Years

Healthy Volunteers

Not accepted

Interventions

• THRIVE Intervention — BEHAVIORAL
  The THRIVE Clinical Pathway is a standardized transitional care clinical pathway that supports Medicaid insured or Medicaid eligible individuals following hospitalization.

Study Details

The goal of this stepped wedge pragmatic trial is to compare referral patterns and post discharge outcomes in Medicaid insured individuals discharge following a hospitalization\]. The aims are to 1) evaluate the implementation of the THRIVE clinical pathway, including feasibility, appropriateness, and acceptability and 2) examine referral patterns, 30- day readmission and Emergency Department (ED) utilization patterns for participants who receive THRIVE support services. During hospitalization participants will receive a referral to home care services and will be seen by a home care nurse within 48 hours following discharge. A discharging physician or Advanced Practice Provider will maintain clinical oversight for 30 days or until the patient sees primary care provider or specialist. A Care Coordination Team conducts weekly case conferences to ensure social and health needs are being addressed for 30 days post-discharge. Researchers will compare Medicaid insured patients discharged during the study, to those receiving usual care to determine if there are differences in post-acute utilization outcomes.

Key Dates

Start date

Mar 27, 2023

Status verified

Jul 2025

Primary completion

May 30, 2026

Completion

Jun 30, 2026

Study Design

Enrollment

267 participants (estimated)

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Arms

• Experimental: THRIVE Intervention
  1 month intensive post discharge case management and care coordination.
• No Intervention: Usual Care
  Discharge to home without intensive post acute case management or care coordination.

Primary Outcome Measure

Rates of Referrals to Homecare [ Time Frame: Through study completion, an average of 18 months ]

Locations (1)

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