---
title: PATient Navigator to rEduce Readmissions
nct_id: NCT02114515
overall_status: COMPLETED
phase: NA
sponsor: University of Illinois at Chicago
study_type: INTERVENTIONAL
primary_condition: Chronic Obstructive Pulmonary Disease
countries: United States
canonical_url: "https://parkinsonspathways.com/agent/trials/NCT02114515.md"
clinicaltrials_gov: "https://clinicaltrials.gov/study/NCT02114515"
ct_last_update_post_date: 2019-02-15
last_seen_at: "2026-05-12T06:47:17.784Z"
source: ClinicalTrials.gov (mirrored, no enrichment)
---
# PATient Navigator to rEduce Readmissions

**NCT ID:** [NCT02114515](https://clinicaltrials.gov/study/NCT02114515)

## Key Facts

- **Status:** COMPLETED
- **Phase:** NA
- **Study Type:** INTERVENTIONAL
- **Target Enrollment:** 1029
- **Lead Sponsor:** University of Illinois at Chicago
- **Collaborators:** Patient-Centered Outcomes Research Institute, Society of Hospital Medicine, COPD Foundation, University of Kentucky, Mended Hearts, American Heart Association, Sickle Cell Disease Association of Illinois, AcademyHealth, The National Association of Social Workers Foundation, Respiratory Health Association, University of Illinois Sickle Cell Patient Council, National Jewish Health, Baystate Medical Center
- **Conditions:** Chronic Obstructive Pulmonary Disease, Heart Failure, Sickle Cell Disease, Myocardial Infarction, Pneumonia
- **Start Date:** 2014-07
- **Completion Date:** 2016-10
- **CT.gov Last Update:** 2019-02-15

## Brief Summary

Staying out of the hospital is valued by patients and their caregivers. Their interests converge with those of hospitals now that high 30-day readmission rates for some conditions place hospitals at risk for financial penalties from the Centers for Medicare and Medicaid Services. This study focuses on developing and testing a program that combines a community health worker (lay patient advocate, acting as a "Patient Navigator") and a peer-led telephone support line to improve patient experience during hospital to home transition.

## Eligibility

- **Minimum age:** 18 Years
- **Sex:** ALL
- **Healthy Volunteers:** No

```
Inclusion Criteria:

1. Age 18 years or older on date of hospital admission
2. Hospitalized at the University of Illinois Hospital, Chicago
3. Admission diagnosis, per treating physician, of pneumonia, COPD, sickle cell disease, heart failure, or myocardial infarction
4. Receive medical care on an inpatient medical service

Exclusion Criteria:

1. Unable to understand and speak English
2. Unable/decline to give informed consent
3. Previous participant in PArTNER
4. Planned transfer to another acute care facility
5. Planned discharge to facility other than home (e.g. long term care facility)
6. Currently on hospice or plans to discharge home to hospice
7. Current plans to leave against medical advice
```

## Arms

- **Usual Care** (OTHER) — Hospital usual care

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.
- **Usual Care + PArTNER** (EXPERIMENTAL) — Navigator intervention: (Community health worker, peer-led telephone support line, usual care)

Hospital usual care: Written discharge instructions provided to patients prior to hospital discharge.

Community health worker: The community health worker provides social support, literacy appropriate education, and acts as a conduit between the patient and the patient's medical team

Peer-led telephone support line: The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

## Interventions

- **Hospital usual care** (BEHAVIORAL) — Written discharge instructions provided to patients prior to hospital discharge.
- **Navigator intervention** (BEHAVIORAL) — A Patient Navigator will provide social support, literacy appropriate education, and act as a conduit between the patient and the patient's medical team
- **Peer-led telephone support line** (BEHAVIORAL) — The peer-led telephone support line will provide social support, peer-to-peer coaching, and facilitate communication with the patient's medical care team.

## Primary Outcomes

- **PROMIS Emotional Distress-Anxiety (v1.0, SF4a)** _(time frame: 30 days post discharge)_ — Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score \<0 indicates improvement. A change equal to 0 indicates no change. A change \>0 indicates worsening.
- **PROMIS Informational Support (v2.0, SF4a)** _(time frame: 30 days post discharge)_ — Change in T-score from baseline to 30 days post discharge (30 days minus baseline).

A change in t-score \<0 indicates worsening. A change equal to 0 indicates no change. A change \>0 indicates improvement.

## Secondary Outcomes

- **PROMIS Emotional Support (v2.0, SF4a)** _(time frame: 30 days post discharge)_
- **PROMIS Instrumental Support (v2.0, SF4a)** _(time frame: 30 days post discharge)_
- **PROMIS Global Health, Physical (v1.1, SF)** _(time frame: 30 days post discharge)_
- **PROMIS Global Health, Mental (v1.1, SF)** _(time frame: 30 days post discharge)_
- **PROMIS Emotional Distress-Anxiety (v1.0, SF4a)** _(time frame: 60 days post discharge)_
- **PROMIS Informational Support (v2.0, SF4a)** _(time frame: 60 days post discharge)_
- **PROMIS Emotional Support (v2.0, SF4a)** _(time frame: 60 days post discharge)_
- **PROMIS Instrumental Support (v2.0, SF4a)** _(time frame: 60 days post discharge)_
- **PROMIS Global Health, Physical (v1.1, SF)** _(time frame: 60 days post discharge)_
- **PROMIS Global Health, Mental (v1.1, SF)** _(time frame: 60 days post discharge)_
- **Death** _(time frame: 30 days post discharge)_
- **Death** _(time frame: 60 days post discharge)_
- **Re-hospitalization or Death** _(time frame: 30 days post discharge)_
- **Re-hospitalization or Death** _(time frame: 60 days post discharge)_
- **ED Visit, Re-hospitalization, or Death** _(time frame: 30 days post discharge)_
- **ED Visit, Re-hospitalization, or Death** _(time frame: 60 days post discharge)_
- **Outpatient Healthcare Visit** _(time frame: 14 days post discharge)_
- **Outpatient Healthcare Visit** _(time frame: 14 days post discharge)_

## Locations (1)

- University of Illinois Hospital, Chicago, Illinois, United States

## Recent Field Changes (last 30 days)

- `status.overallStatus` — added _(2026-05-12)_
- `status.primaryCompletionDate` — added _(2026-05-12)_
- `status.completionDate` — added _(2026-05-12)_
- `status.lastUpdatePostDate` — added _(2026-05-12)_
- `design.phases` — added _(2026-05-12)_
- `design.enrollmentCount` — added _(2026-05-12)_
- `eligibility.criteria` — added _(2026-05-12)_
- `eligibility.minAge` — added _(2026-05-12)_
- `eligibility.sex` — added _(2026-05-12)_
- `outcomes.primary` — added _(2026-05-12)_
- `outcomes.secondary` — added _(2026-05-12)_
- `armsInterventions.arms` — added _(2026-05-12)_
- `armsInterventions.interventions` — added _(2026-05-12)_
- `sponsor.lead` — added _(2026-05-12)_
- `sponsor.collaborators` — added _(2026-05-12)_
- `results.hasResults` — added _(2026-05-12)_
- `locations.university of illinois hospital|chicago|illinois|united states` — added _(2026-05-12)_

---

*Canonical: https://parkinsonspathways.com/agent/trials/NCT02114515.md*  
*Source data (authoritative): https://clinicaltrials.gov/study/NCT02114515*  
*This page is a raw mirror with no AI summary, no editorial enrichment, and no Parkinson's-specific filtering.*