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.
Medicaid insured
Residing in the state of Pennsylvania
Experienced a hospitalization at study hospital
Agrees to home care at partner home care setting.
Individuals under age 18
Parallel
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.
Rates of Referrals to Homecare
We will evaluate changes in home care referrals between case managers exposed to the intervention compared to those who were not
Rates of Readmissions
We will evaluate the rate of readmissions over the course of the study for THRIVE participants compared to those receiving usual care
Rates of Emergency Department Visit
We will evaluate the rate of ED visits over the course of the study for THRIVE participants compared to those receiving usual care.
Primary Care or Specialist Visit
We will compare the rates of primary care provider and specialist visits within 30 days following discharge compared to those receiving usual care
Feasibility, Acceptability, Appropriateness, Workload
We will conduct interviews of clinicians at the conclusion of the study to gather perceptions of the THRIVE clinical pathway and facilitators and barriers to engaging with the intervention
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University of Pennsylvania
Lead sponsor
Agency for Healthcare Research and Quality (AHRQ)
Collaborator
