Communication Outreach for Navigation and Needs-based Care Transitions (CONNECT): A Pilot Randomized Controlled Trial
Boston Medical Center
Summary
Hospital discharge is a dangerous time for patients: one in five will suffer an adverse event, such as a medication error, and nearly 25% will be readmitted within 30 days. This time is even more dangerous for patients with who face communication barriers, including those with non-English language preference (NELP), low health literacy, and the elderly. The investigators will pilot a post-discharge educational intervention to reinforce written discharge instructions (known as the After Visit Summary or AVS) using a randomized controlled trial design (2:1 intervention: control). The control group will receive current standard of care discharge education which includes a nurse reviewing their AVS and an automated call in English that allows patients to numerically select types of problems/questions that are then escalated to a nurse who should return their call within a few days. The intervention group will receive the standard of care discharge education with the AVS and an additional post-discharge educational call delivered by a registered nurse or other qualified health professional with the option to have written instructions professionally translated and sent via MyChart message--if available in their preferred language.
Eligibility
- Age range
- 18+ years
- Sex
- All
- Healthy volunteers
- No
Inclusion Criteria: * Registered language in Epic (written or spoken) is Spanish, Haitian Creole, Portuguese, Cape Verdean, or Vietnamese * Admitted to medicine team at Boston Medical Center (BMC) * Being discharged home (to the community) Exclusion Criteria: * On airborne infections precautions at time of recruitment * On C diff precautions at time of recruitment * On suicide precautions at time of recruitment * Nurse report of participant displaying cognitive impairment, ongoing delirium, or aggression * Discharge observed during a prior admission
Interventions
- OtherAdditional post discharge phone call
24-72 hours after hospital discharge, a nurse will call participants to review the written After Visit Summary (AVS) given at discharge, including primary diagnosis, self-care instructions, emergency plan, medication changes, how and why to take medication, and scheduled follow up. These phone calls will take on average 10-15 minutes.
Location
- Boston Medical CenterBoston, Massachusetts