Improving Care Transitions for Medicaid Insured Individuals With Co-occurring Serious Mental Illness

Conditions

• Care Transitions

Eligibility Criteria

Sex

ALL

Age

18 Years - N/A

Healthy Volunteers

Accepted

Interventions

• Thrive Intervention — BEHAVIORAL
  • The THRIVE Clinical Pathway is a standardized transitional care clinical pathway that supports Medicaid insured or Medicaid eligible individuals being managed for both chronic diseases and serious mental illness following hospitalization.

Study Details

This study aims to evaluate the THRIVE clinical pathway at HUP, focusing on supporting Medicaid-insured individuals, including those with serious mental illness, following hospitalization. The study will assess clinician/administrator perspectives on the pathway's feasibility, appropriateness, and acceptability and analyze referral patterns and post-discharge outcomes. The objectives are: 1. To conduct a qualitative study evaluating the implementation of THRIVE, particularly its adaptation to include patients with serious mental illness. 2. To examine referral patterns, 30-day readmission rates, and ED utilization for THRIVE participants, comparing them with those receiving standard care. Participants will be referred to home care services during hospitalization and seen by a home care nurse within 48 hours post-discharge. A discharging physician or Advanced Practice Provider will oversee care for 30 days or until a primary care or specialist visit. The Care Coordination Team will hold weekly case conferences for 30 days post-discharge to address both health and mental health needs. The study will compare outcomes of Medicaid-insured patients, including those with serious mental illness, to those receiving usual care.

Key Dates

Start date

Apr 15, 2024

Status verified

Apr 2026

Primary completion

Jul 1, 2026

Completion

Oct 1, 2026

Study Design

Enrollment

267 participants (estimated)

Allocation

RANDOMIZED

Intervention model

PARALLEL

Primary purpose

TREATMENT

Arms

• Experimental: THRIVE Intervention
  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 ]

Central Contacts

• Jacqueline M Brooks Carthon, PhD,RN
  2158988050
  [email protected]
• Erin Babe, MPH
  2158984417
  [email protected]

Locations (1)

Find similar trials in Philadelphia, PA

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