Addressing Safety, Quality, and Cost of Care Through a Telehealth Outpatient Transitional Care Model: Protocol for a Pragmatic Randomized Controlled Trial
Notice bibliographique
Résumé
BACKGROUND: People with multimorbidity have complex health care needs, resulting in high health service use, hospital readmission rates, and support needs. To prevent unnecessary hospital readmissions, effective coordination during the transition from hospital to primary care is essential; the transitional care model (TCM) is an effective approach to achieve this. This study will adapt the TCM, focusing on a nurse-led telehealth-based follow-up transition coordination service to enhance continuity between hospital and primary care, aiming to reduce unnecessary hospital readmissions and improve patient transitions. OBJECTIVE: This study aims to assess the impact of a TCM on 3-month readmission rates in people with multimorbidity after discharge in an Australian context. Other objectives include evaluating the rate of re-presentation to hospital and overall length of hospital stay within 1, 6, and 12 months of discharge from the index admission; conducting a cost analysis of the transitional service model of care; evaluating the patient experience with the transition service; assessing patients' symptom burden before and after transitional support service intervention; and evaluating patients' quality of life, self-efficacy, and symptom management before and after intervention. METHODS: The study design is a multicenter, pragmatic randomized controlled trial of patients with multimorbidity; therefore, real-world clinical practices, and operations will be the considerations within the research design elements. A mixed methods approach using quantitative and qualitative data collection methods will be used. The study setting incorporates 2 hospitals, initially commencing at the Queen Elizabeth Hospital (a 355-bed acute and subacute teaching hospital) and then at the Royal Adelaide Hospital (an 880-bed acute care teaching hospital), both located within the Central Adelaide Local Health Network, South Australia. We will include 3 to 6 medical units and wards. The intervention will focus on nurse-led transition assessment and care planning and telehealth transition coordination support for people with multimorbidity for 6 to 10 weeks following hospital discharge. RESULTS: This project received ethics approval (17554) on June 29, 2023, and was registered with the Australian New Zealand Clinical Trials Registry on February 15, 2024 (12624000142538). The study commenced on July 1, 2023; data collection started in February 2024 and was completed on March 31, 2025. Finalized results are expected in March 2026. CONCLUSIONS: The Central Adelaide Local Health Network currently lacks a process to assess or manage readmission risks for people with multimorbidity, despite evidence linking transitional care to reduced rehospitalizations. Our feasibility study highlighted the effectiveness of a transition coordinator role in supporting patients' return to home and community. Progressing this work, an adapted TCM, with telehealth-based follow-up and home and health care support, will enhance continuity between hospital and primary care, aiming to reduce unnecessary readmissions and improve patient transitions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12624000142538; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=383721. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/71847.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,063 | 0,054 |
| Méta-épidémiologie (sens strict) | 0,008 | 0,004 |
| Méta-épidémiologie (sens large) | 0,015 | 0,008 |
| Bibliométrie | 0,004 | 0,006 |
| Études des sciences et des technologies | 0,004 | 0,005 |
| Communication savante | 0,006 | 0,004 |
| Science ouverte | 0,004 | 0,003 |
| Intégrité de la recherche | 0,008 | 0,010 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,071 | 0,010 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».