Recruiting

Observational Study

Sponsor:

University of Wisconsin, Madison

Code:

NCT06581224

Conditions

High-need, High-complexity

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Not accepted

Interventions

Primary Hospital Provider Team

Study Details

Brief summary:

The goal of this pragmatic clinical trial is to learn if it is possible to implement a Primary Hospital Provider (PHP) team that aims to improve continuity of care for patients who are frequently hospitalized. The main question it aims to answer is: Are patients assigned to the PHP team more likely to be assigned to this team during a follow up hospitalization? Researchers will compare this to similar patients assigned to receive usual care. Some patient participants (or their caregivers) from both the PHP team and usual care groups will be asked to participate in interviews to help researchers understand the needs of patients who are frequently admitted and the care they receive.

Conditions

High-need, High-complexity

Study ID

NCT06581224

Start date

Jan 9, 2025

Status verified date

Jan, 2026

Completion date

Jan, 2028

Anticipated

Primary completion date

Jan, 2028

Anticipated

Eligibility Criteria

Eligibility Criteria

Sex: All

Age: 18+

Healthy Volunteers: Not accepted

Inclusion Criteria:

  • Age greater than 18 at the time of index admission
  • Two or more hospitalizations to a general medicine service at UW Health (University Hospital or East Madison Hospital) within the past 12 months AND an EPIC Readmission Risk Score of greater than a predetermined value

Exclusion Criteria:

  • Outpatient primary care provider is part of the UW Health Family Medicine service that currently admits their own patients to a separate service at University Hospital
  • Patients with an oncologic diagnosis for which they are actively receiving chemotherapy or immunotherapy
  • Incarcerated persons
  • Pregnant women

Study Design

Enrollment

1200 participants

Anticipated

Allocation

Randomized

Intervention Model

Parallel Assignment

Primary purpose

Health Services Research

Interventions and Outcome Measures

Arms

experimental: PHP Team

PHP Team

no intervention: Usual Care

Usual Care hospital medicine team

Interventions

Primary Hospital Provider Team

The PHP team aims to enhance continuity during hospital readmissions with a consistent cohort of seven hospital medicine physicians and two advanced practice providers (APPs). To improve care transitions, the team will have an integrated case manager who will continue following PHP patients during subsequent hospitalizations. Physicians will follow a standard seven-day service schedule, with the two APPs alternating five-to-seven-day periods. Daily huddles between physicians and APPs will further promote continuity. During the index admission, the PHP team will create a care plan in consultation with the patient to improve standardization of inpatient care and transition to outpatient settings. Communication will be a core tenet of the team, with scheduled monthly team meetings of physicians, APPs, case manager, dyad partner, and representatives from nursing and therapy services to revise individualized care plans for PHP patients and brainstorm solutions for complex challenges.

Primary outcome measure

  • Number of patients readmitted to the PHP team [ Time Frame: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months ]
  • Number of patients readmitted to usual care team [ Time Frame: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months ]
  • Percentage of patients readmitted to the PHP team [ Time Frame: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months ]
  • Percentage of patients readmitted to usual care team [ Time Frame: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months ]

Central Contacts and Locations

Central contacts

Sara Westergaard, MD, MPH

608-261-1150swesterga@medicine.wisc.edu

Locations

UW Hospital and Clinics

Recruiting

Madison, Wisconsin, United States, 53792

More Information

Sponsor

University of Wisconsin, Madison

Last update posted

Jan 26, 2026

Last verified

Jan, 2026

Trial information was received from ClinicalTrials.gov and was last updated on 2026-09-10. This information was provided to ClinicalTrials.gov by University of Wisconsin, Madison on 2026-01-26.