NLM logo

National Information Center on Health Services Research and Health Care Technology (NICHSR)

HSRProj (Health Services Research Projects in Progress)

Information about ongoing health services research and public health projects


Specialized community disease management to reduce substance use and hospital readmissions
Investigator (PI): Brooks, Adam
Performing Organization (PO): (Current): Public Health Management Corporation / (215) 985-2500
(Past): Treatment Research Institute (TRI) / (215) 399-0980
Supporting Agency (SA): Patient-Centered Outcomes Research Institute (PCORI)
Initial Year: 2014
Final Year: 2019
Record Source/Award ID: PCORI/IHS-1306-03482
Funding: Total Award Amount: $2,133,963
Award Type: Contract
Award Information: PCORI: More information and project results (when completed)
Abstract: Background: Hospitalized patients with substance use disorders (SUDs) face significant complications in their medical care. They are more likely to be discharged against medical advice, rehospitalized after discharge, and experience personal chaos and reduced family support. Due in large part to recent changes in Medicaid policy, hospital systems are moving quickly to implement hospital-based and community disease management strategies to help patients transition post-discharge. However, few hospitals provide specialized follow-up for discharged patients with SUDs. Inpatients with substance use disorders may not be served well by existing disease management programs intended to reduce rehospitalizations because the programs do not attend to their SUD and related psychosocial problems (isolation, unstable housing, mental illness, HIV infection, etc.). Objectives: This proposal, conducted in collaboration with the Institute for Population Health at Temple University Hospital, is highly significant because it will test whether an extended, specialized community disease management program can improve outcomes over an existing nurse navigator disease management strategy for patients with co-morbid medical conditions and SUDs. Methods: This project will test a specialized post-discharge program for hospitalized individuals with substance use disorders, and the program will address both SUDs and medical issues after discharge. Hospitalized patients at Temple University Hospital (TUH) who have been admitted for congestive heart failure, heart attack, or pneumonia will be screened for SUDs. Patients who meet SUD criteria will be eligible to participate in the study. We will enroll 222 inpatients with co-occurring medical conditions and SUDs and will randomly assign them to either 1) the Temple Advantage program a 30-day, post-discharge program currently operated by TUH that consists of medical monitoring by workers who have no special training in working with SUD patients; or 2) the Specialized Community Disease Management program (the experimental condition) a 90-day program that will employ specialized teams including a trained clinical social worker and a peer-specialist community health worker who will provide evidence-based telephone continuing care, home visits, and increased focus on patients' substance use. Outcomes: All participants will be followed at 3 and 6 months post-discharge, and evaluated for substance use, HIV risk, and 6-month service utilization outcomes, including inpatient, emergency department, and outpatient medical and SUD treatment services. This moment in the evolution of the U.S. health care system provides an opportunity to demonstrate that treatment for SUDs, skillfully and flexibly applied across inpatient and community settings, can impact the health outcomes and service utilization of inpatients with SUDs, thereby significantly improving patient care while simultaneously reducing overall costs to the system. More on this project: In Care Transitions, a Chance to Make or Break Patients' Recovery--A narrative on what happens when patients are harmed by poorly executed transitions between healthcare settings. https://www.pcori.org/research-in-action/care-transitions-chance-make-or-break-patients-recovery
MeSH Terms:
  • Community Health Workers
  • * Disease Management
  • Evidence-Based Medicine
  • Health Care Costs
  • Heart Failure /complications
  • /therapy
  • Hospitals
  • Humans
  • Inpatients
  • Medicaid
  • Myocardial Infarction /complications
  • /therapy
  • Outcome Assessment, Health Care
  • Patient Discharge
  • * Patient Readmission
  • Pennsylvania
  • Pneumonia /complications
  • /therapy
  • Randomized Controlled Trials as Topic
  • Social Work
  • Substance-Related Disorders /*prevention & control
  • /therapy
  • Telemedicine
Country: United States || United States
State: Pennsylvania || Pennsylvania
Zip Code: 19103 / 19106
UI: 20143570
CTgovId: NCT02059005
Project Status: Completed
Record History: ('2017: Project extended to 2017',) ('2018: Project extended to 2018 and changed PO.',) ('2019: Project extended to 2019.',)