Optimizing Care Transition Process for Older Colorectal Surgery Patients
Trial statusRecruiting
Trial phaseNot applicable
Trial typeInterventional
Biological sexAll
Age65+
SponsorMassachusetts General Hospital
About this trial
The goal of this study to test if a care transition intervention designed for older colorectal surgery patients would improve outcomes after discharge. It will assess the feasibility of the intervention.
Eligibility criteria
This trial does not accept healthy volunteersQualifiers
Adult patients (>65 years old)
Scheduled to undergo an elective colorectal surgery procedure
Ability to provide informed consent
Disqualifiers
Emergent, non-elective colorectal procedures
Non-English Speaking
Trial design
Design model
Single group
Treatments tested in this trial
OSCAR-S Care Transition Model
BehavioralPatients and families in the intervention arm will receive touch points from the surgery nurse coach to support their care transition from hospital to home after surgery.
Treatment groups
30 Participants
are divided into 1 treatment groupGroup A: OSCAR-S Care Transition ModelExperimental treatment 1 intervention
Trial outcomes
Primary outcomes
1
Postdischarge 30-day readmission or death
Composite incidence of all-cause hospital readmission or death within 30 days of discharge, measured by medical record review and hospital administrative data.
Time frame
30 daysSecondary outcomes
1
Reach
Percentage of eligible older colorectal surgery patients who are enrolled in the OSCAR-S intervention, measured by comparing enrollment logs against surgical case lists.
Time frame
12 months2
Fidelity
Continued adherence to the OSCAR-S protocol at 12 months, measured by a fidelity checklist (e.g., completion of required nurse coach touch points, red-flag education, follow-up scheduling) reviewed by study staff.
Time frame
12 months3
Adoption
Percentage of eligible providers (surgeons, hospitalists, primary care physicians) who engage in at least one documented communication with the nurse coach during the patient's transition period, measured by electronic health record (EHR) audit logs.
Time frame
12 months4
Effectiveness - Patient Satisfaction
Patient-reported satisfaction with the care transition process, measured by the Care Transitions Measure (CTM-3) total score (range 0-100; higher scores indicate better satisfaction). Higher scores indicate better (more positive) satisfaction with the care transition.
Time frame
30 daysSponsors and contacts
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Source ClinicalTrials.gov