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Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study



Minority-serving hospitals (MSHs) need evidence-based strategies tailored to the populations they serve to improve patient-centered outcomes after hospitalization.


We conducted a pragmatic randomized clinical trial (RCT) from October 2014 to January 2017 at a MSH comparing the effectiveness of a stakeholder-supported Navigator intervention vs. Usual care on post-hospital patient experience, outcomes, and healthcare utilization. Community health workers and peer coaches delivered the intervention which included (1) in-hospital visits to assess barriers to health/healthcare and to develop a personalized Discharge Patient Education Tool (DPET); (2) a home visit to review the DPET; and (3) telephone-based peer coaching. The co-primary outcomes were between-group comparisons of 30-day changes in Patient-Reported Outcomes Measurement Information System (PROMIS) measures of anxiety and informational support (minimum important difference is 2 to 5 units change); a p-value <0.025 was considered significant using intention-to-treat analysis. Secondary outcomes included death, ED visits, or readmissions and measures of emotional, social, and physical health at 30 and 60 days.


We enrolled 1029 adults hospitalized with heart failure (28%), pneumonia (22%), MI (10%), COPD (11%), or sickle cell disease (29%). Over 80% were non-Hispanic Black. Overall, there were no significant between-group differences in the 30-day change in anxiety (adjusted difference: −1.6, 97.5% CI −3.3 to 0.1, p=0.03), informational support (adjusted difference: −0.01, 97.5% CI −2.0 to 1.9, p=0.99), or any secondary outcomes. Exploratory analyses suggested the Navigator intervention improved anxiety among participants with COPD, a primary care provider, a hospitalization in the past 12 months, or higher baseline anxiety; among participants without health insurance, the intervention improved informational support (all p-values <0.05).


In this pragmatic RCT at a MSH, the Navigator intervention did not improve post-hospital anxiety, informational support, or other outcomes compared to Usual care. Benefits observed in participant subgroups should be confirmed in future studies.

Trial Registration identifier: NCT02114515

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We acknowledge the helpful oversight by our program officer, Carly Parry, PhD, MSW, MA. We also express our appreciation for the patients who elected to participate in the study, as well as their caregivers, clinicians and staff at UI Health, PArTNER research team, members of the PArTNER Data and Safety Monitoring Board (DSMB), members of the PArTNER External Advisory Committee, and the University of Illinois Institutional Review Board.


We received funding from the Patient-Centered Outcomes Research Institute (contract # IH 12-11-4365).

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Correspondence to Stephanie L. LaBedz MD.

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Conflict of Interest

Dr. Krishnan reports contract funding from the Patient-Centered Outcomes Research Institute during the conduct of the study. Dr. Williams reports contract funding from the Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study; grants from NHLBI, contract funding from CMS, other contract funding from PCORI, consulting from OptumHealth Care Solutions, LLC, personal fees from Northwestern University, personal fees from Society of Hospital Medicine, personal fees from Oakstone Publishing CME, personal fees from Alabama Hospital Association, and personal fees from Academic Medical Centers outside the submitted work. Dr. DiDomenico reports advisory board participation for Abiomed and grants from CSL Behring outside the submitted work. Drs. LaBedz, Prieto-Centurion, Mutso, Basu, Joo, Pickard, Pittendrigh, Ms. Bracken, and Mr. Illendula have no conflicts of interest to disclose.

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LaBedz, S.L., Prieto-Centurion, V., Mutso, A. et al. Pragmatic Clinical Trial to Improve Patient Experience Among Adults During Transitions from Hospital to Home: the PArTNER study. J GEN INTERN MED (2022).

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