GeriatricsPROUSTNCT02421133
Impact of a Transitional Care Program on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward
A study testing Transitional care program. in people with Geriatrics, run by Hospices Civils de Lyon at 9 sites in France.
Trial summary
In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be… Read more about this study
- Who is it for?
- Ages 75 years and older
- Conditions the study is for
- Geriatrics
- What is being tested?
- Transitional care program.
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 630 participants
- Where
- 9 sitesFrance
- Study dates
- Jul 2015to 30 Nov 2016
- Phase
- Interventional
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 75 years and older
- All sexes
- No healthy volunteers
- Older adult
Who may be able to join
- Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
- Aged 75 or older.
- Leaving at home and with home as the planned discharge after the admission.
- At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).
Who cannot join
- Patient leaving in a retirement home.
- Patient hospitalized at home.
- Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission
Trial locations and contacts
9 sites in 1 country.
9 sites in 1 country
France9 sites
CH Gériatrique des Monts d'Or
Albigny-sur-Saône, 69250
CH Bourg-en-Bresse
Bourg-en-Bresse, 01012
Centre Hospitalier Alpes Léman
Contamine-sur-Arve, 74130
Hôpital Édouard Herriot
Lyon, 69437
Centre Hospitalier Lyon Sud
Pierre-Bénite, 69495
CHG Annecy
Pringy, 74374
CH Saint-Chamond
Saint-Chamond, 42400
Clinique des portes du sud
Vénissieux, 69200
CH Villefranche
Villefranche, 69655
About this study
Official title: Impact of a Transitional Care Program Involving an Advanced Practice Nurse on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward (PROUST Study)
In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.
Read the detailed description
The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,
- Conditions
- Geriatrics
- Being tested
- Transitional care program., standard care program
- Keywords
- Care transition program, Patient readmission, Transition Nurse, Stepped wedge, elderly
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Transitional care program.Other
During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge.
The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring.
During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit.
standard care programOther
The patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work.
| Study group | Role | What they receive |
|---|---|---|
| Transitional care program. | Experimental | The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge. Receives: Other: Transitional care program. |
| standard care program | Other | No intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention). Receives: Other: standard care program |
What is being measured
The primary outcome is the main question the study is designed to answer.
30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.
Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).
Measured: Within 30 days after hospital discharge.
Secondary outcomes (10)
Length of stay in the short stay geriatric ward (index hospitalization)
Measured: Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days
Unscheduled hospital readmissions or emergency room visits
Measured: Within 30 and 90 days after the index hospital discharge.
Free-hospitalization survival
Measured: Within 30 and 90 days after the index hospital discharge.
Mortality rate
Measured: Within 30 and 90 days after the index hospital discharge.
Adverse events (i.e. falls)
Measured: Within 30 days after the index hospital discharge.
Quality of life.
Measured with the French version of the EUROQOL-5D.
Measured: Within 30 days after the index hospital discharge.
Patients' satisfaction care transition programme
Measured with the Care Transition Measure® questionnaire.
Measured: Within 30 days after the index hospital discharge.
Delay between the index hospital discharge and the implementation of home care.
Measured: Within 30 days after the index hospital discharge.
Number of contacts between the transition nurse and the primary care providers or the hospital providers after discharge
Measured: Within 30 days after the index hospital discharge.
Costs of unscheduled hospital readmission or emergency visit
Hospital and community care costs after discharge
Measured: 30 days after discharge
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted20 Apr 2015 (estimated)
- Study startJul 2015
- Primary completion30 Nov 2016
- Study completion30 Nov 2016
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Publications (1)Papers the sponsor has linked to this study.
- Other trials for GeriatricsStudies of the same condition, open and under way.
- More trials run by Hospices Civils de LyonThe sponsor's other registered studies.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase N/A
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Enrolment
- 630 participants (actual)
Sponsor and investigators
- Lead sponsor
- Hospices Civils de Lyon
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
- Investigators
- Marc Bonnefoy, Principal investigator, Centre Hospitalier Lyon Sud-Hospices Civils de Lyon
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT02421133
- Sponsor's protocol ID
- 2014.874
- Acronym
- PROUST
- Status last verified
- Dec 2025
- First submitted
- 9 Mar 2015
- Last updated
- 19 Dec 2025
- Results posted
- No
- Data monitoring committee
- No
Publications
Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016 Mar 3;16:57. doi: 10.1186/s12877-016-0233-2.
PubMed 26940678
Study at a glance
From the registry record, last updated by the sponsor on 19 Dec 2025. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Impact of a Transitional Care Program Involving an Advanced Practice Nurse on 30-Day Hospital Readmissions for Elderly Patients Discharged From a Short Stay Geriatric Ward (PROUST Study)
- ClinicalTrials.gov ID
- NCT02421133
- Acronym / sponsor ID
- PROUST / 2014.874
- Conditions
- Geriatrics
- Keywords
- Care transition program, Patient readmission, Transition Nurse, Stepped wedge, elderly
- Study type
- Interventional
- Recruitment status
- Completed
- Enrolment
- 630 participants (actual)
- Lead sponsor
- Hospices Civils de LyonUniversity, hospital or other
- Study start
- Jul 2015
- Primary completion
- 30 Nov 2016 (actual)
- Study completion
- 30 Nov 2016 (actual)
- First posted
- 20 Apr 2015 (estimated)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
In France, it has be estimated that the hospital readmission rate within 30 days of patients aged 75 or older is 14% (IC95% [12.0-16.7]), nearly a quarter being avoidable. There is evidence that interventions "bridging" the transition from hospital to home involving a dedicated professional (usually nurses) would be most effective in reducing the risk of readmission, but the level of evidence of current studies is low. Our study aims to assess the impact of a program of transitional care from hospital to home for people of 75 years old or more admitted to acute care.
Detailed description
The study is a stepped wedge randomized cluster study. Intervention: The transition care program, involving a dedicated advanced practice nurse, will include: 1) during the patient's stay in hospital: an individualized needs-based comprehensive discharge plan and a transitional care record ; the notification of the primary care physician about inpatient care and hospital discharge; 2) the day of the discharge: specific explanations about the organization of home care provided by the transition care nurse to the patient; 3) during 4 weeks after discharge: monitoring patients and caregivers regularly through home visits and/or telephone contact,
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Transitional care program. | Experimental | Other: Transitional care program.The transitional care program from hospital to home will be implemented at three steps: during the patient's stay in hospital, the day of the discharge and during 4 weeks after discharge. |
| standard care program | Other | Other: standard care programNo intervention liable to affect the care provided to the patients, the organization of care or the practices of health care professionals will be implemented during the control period (time steps without intervention). |
Who may qualify
- Ages
- 75 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Older adult
Key inclusion criteria (4 listed)
- Patient hospitalized for 48 hours or more in one of the acute geriatric service participating to the study.
- Aged 75 or older.
- Leaving at home and with home as the planned discharge after the admission.
- At risk of hospital readmission emergency visit rates after discharge (if he has two or more of the following criteria (taken from the Triage Risk Screening Tool and from the 2013 French recommendation)).
Key exclusion criteria (3 listed)
- Patient leaving in a retirement home.
- Patient hospitalized at home.
- Patient leaving at home but at 30 km (18 miles) or more from the service of his index admission
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Transitional care program.During the patient's stay in hospital, the transition nurse creates a transitional care file including information about the patient (inpatient medical and nurse care plan, medications), the discharge plan, and the contact information of the relevant primary care providers. She notifies the patient's primary care physician of the date of the discharge to home, of the potential medical problems and of the discharge care plan; a primary care physician visit is planned the month following the discharge. The day of the hospital discharge: meeting with the patient to review the follow-up recommendations. The transition nurse verifies that the medications are prescribed accordingly with the discharge plan, that the patient and his caregiver understand the prescription and are informed with the planned appointments and the biological monitoring. During 4 weeks after the hospital discharge: follow-up by the transition nurse once a week, alternately by telephone and home visit. | Other | Transitional care program. |
| standard care programThe patients will be discharged according to the usual care plan of each participating hospital. The medical team does a medical and geriatric assessment of the patients according to the recommendations. The communication of information to the primary care providers (nurse, primary care physician…) is left to the discretion of the medical teams of the discharging hospitals, according to their habits of work. | Other | standard care program |
Primary outcome
30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge.
Time frame: Within 30 days after hospital discharge.
Unscheduled hospital readmissions are hospitalizations that are not planned at the moment of the discharge (for example: hospitalization after an emergency visit or upon request of the primary care physician).
10 secondary outcomes
Length of stay in the short stay geriatric ward (index hospitalization)
Time frame: Patients will be followed for the duration of hospital stay, an expected average between 2 days and 30 days
Unscheduled hospital readmissions or emergency room visits
Time frame: Within 30 and 90 days after the index hospital discharge.
Free-hospitalization survival
Time frame: Within 30 and 90 days after the index hospital discharge.
Mortality rate
Time frame: Within 30 and 90 days after the index hospital discharge.
Adverse events (i.e. falls)
Time frame: Within 30 days after the index hospital discharge.
Quality of life.
Time frame: Within 30 days after the index hospital discharge.
Patients' satisfaction care transition programme
Time frame: Within 30 days after the index hospital discharge.
Delay between the index hospital discharge and the implementation of home care.
Time frame: Within 30 days after the index hospital discharge.
Number of contacts between the transition nurse and the primary care providers or the hospital providers after discharge
Time frame: Within 30 days after the index hospital discharge.
Costs of unscheduled hospital readmission or emergency visit
Time frame: 30 days after discharge
Results and safety
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 19 Dec 2025.
- Results publication: PubMed 26940678Occelli P, Touzet S, Rabilloud M, Ganne C, Poupon Bourdy S, Galamand B, Debray M, Dartiguepeyrou A, Chuzeville M, Comte B, Turkie B, Tardy M, Luiggi JS, Jacquet-Francillon T, Gilbert T, Bonnefoy M. Impact of a transition nurse program on the prevention of thirty-day hospital readmissions of elderly patients discharged from short-stay units: study protocol of the PROUST stepped-wedge cluster randomised trial. BMC Geriatr. 2016 Mar 3;16:57. doi: 10.1186/s12877-016-0233-2.
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Marc Bonnefoy principal investigator
Centre Hospitalier Lyon Sud-Hospices Civils de Lyon
9 sites in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Transitional care program. in people with Geriatrics, run by Hospices Civils de Lyon at 9 sites in France.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 4 inclusion and 3 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: finished, as of the sponsor's last update on 19 Dec 2025. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 9 sites in France. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
Are results available for this study?
The study is completed, but results are not available in the source record. That does not mean the treatment did or did not work.
How can a doctor refer a patient or contact the research team?
The record lists no contact. The official record names the sponsor, who can be asked directly. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
30-Day unscheduled hospital readmission or emergency visit rate after the index hospital discharge. (time frame: Within 30 days after hospital discharge.). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
On the ClinicalTrials.gov record for NCT02421133, which also lists 1 linked publication.
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 19 Dec 2025.