Recruitment

Recruitment Status
Completed

Inclusion Criterias

reside in one of three metro-area counties (Multnomah, Washington, Clackamas)
hospitalized on one of seven inpatient treatment teams
uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and ≤200% poverty level)
reside in one of three metro-area counties (Multnomah, Washington, Clackamas)
hospitalized on one of seven inpatient treatment teams
uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and ≤200% poverty level)

Exclusion Criterias

disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits
HIV positive (HIV+ patients were eligible for overlapping transitional care resources)
plans to enter hospice.
...
disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits
HIV positive (HIV+ patients were eligible for overlapping transitional care resources)
plans to enter hospice.
no access to a working telephone (participants could list a friend or shelter phone)
non-English speakding
not community dwelling (ie not from a long-term care facility or with plans to discharge to skilled nursing facility)

Summary

Conditions
Hospitalization
Type
Interventional
Design
  • Allocation: Randomized
  • Masking: Single (Outcomes Assessor)
  • Primary Purpose: Health Services Research

Participation Requirements

Age
Between 18 years and 125 years
Gender
Both males and females

Inclusion Criterias

reside in one of three metro-area counties (Multnomah, Washington, Clackamas)
hospitalized on one of seven inpatient treatment teams
uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and ≤200% poverty level)
reside in one of three metro-area counties (Multnomah, Washington, Clackamas)
hospitalized on one of seven inpatient treatment teams
uninsured or low-income publicly insured (Medicaid; Medicare/Medicaid; or Medicare without supplemental insurance and ≤200% poverty level)

Exclusion Criterias

disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits
HIV positive (HIV+ patients were eligible for overlapping transitional care resources)
plans to enter hospice.
...
disabling mental illness (as characterized by active psychosis or active suicidal ideation) or severe cognitive deficits
HIV positive (HIV+ patients were eligible for overlapping transitional care resources)
plans to enter hospice.
no access to a working telephone (participants could list a friend or shelter phone)
non-English speakding
not community dwelling (ie not from a long-term care facility or with plans to discharge to skilled nursing facility)

Locations

Portland, Oregon, 97239
Portland, Oregon, 97239

Tracking Information

NCT #
NCT01906645
Collaborators
Not Provided
Investigators
Not Provided