High-need, High-complexityPHP TeamNCT06581224
Implementation of a Primary Hospital Provider (PHP) Team
A study testing Primary Hospital Provider Team in people with High-need, High-complexity, run by University of Wisconsin, Madison at 1 site in United States.
Trial 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. Read more about this study
- Who is it for?
- Ages 18 years and older
- Conditions the study is for
- High-need, High-complexity
- What is being tested?
- Primary Hospital Provider Team
- Could I receive a placebo?
- No, everyone receives an active treatment
- How many people
- 1,200 participants
- Where
- 1 siteUnited States
- Study dates
- 9 Jan 2025to Jan 2028
- Phase
- Interventional
- Are there results?
- Not yet: the study is under way
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 18 years and older
- All sexes
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- 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
Who cannot join
- 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
Trial locations and contacts
1 site in 1 country. Contact the study team or a site near you to ask about taking part.
United States1 site, 1 recruiting
- Recruiting
UW Hospital and Clinics
Madison, Wisconsin, 53792
About this study
Official title: Implementation of a Primary Hospitalist Provider Team to Enhance the Care for High-Need High-Complexity Patients Requiring Hospitalization
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.
Read the detailed description
The overarching goal of this study is to reduce inpatient care fragmentation for high-need, high-complexity (HNHC) patients and improve outcomes by implementing a primary hospital provider (PHP) team. In this study, we will specifically evaluate the feasibility of implementation of this team as well as workforce and operational acceptance, as well as its impact on continuity of hospital medicine care across subsequent admissions.
The study is conducted as a two-arm, pragmatic hybrid type II effectiveness implementation trial with two sequential phases. Phase 1 focuses on initial feasibility and early acceptability of the PHP team. Phase 2 evaluates sustained implementation, reach, and longitudinal continuity outcomes using the same intervention, eligibility criteria, and study procedures. No changes will be made to the intervention, eligibility criteria, or data collection methods between phases.
Study Aims:
Aim 1 Primary Implementation Objective: Compare the fragmentation in hospital medicine care during subsequent admissions for HNHC patients assigned to the PHP team with those continuing to receive usual care.
- Aim 1a (Phase 1): Assess feasibility and early continuity of care during subsequent admissions.
- Aim 1b (Phase 2): Evaluate sustained continuity and re-exposure to the PHP team across repeated hospitalizations over an extended enrollment period.
Aim 2 Primary Exploratory Objective: Explore perceptions of care among HNHC patients and caregivers randomized to the PHP team and to a usual care team.
Aim 3 Secondary Exploratory Objective: Identify operational perceptions of the implementation of the PHP team from a workforce and system-level perspective.
- Conditions
- High-need, High-complexity
- Being tested
- Primary Hospital Provider Team
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
Primary Hospital Provider TeamOther
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.
| Study group | Role | What they receive |
|---|---|---|
| PHP Team | Experimental | PHP Team Receives: Other: Primary Hospital Provider Team |
| Usual Care | No intervention | Usual Care hospital medicine team |
What is being measured
The primary outcome is the main question the study is designed to answer.
Number of patients readmitted to the PHP team
The number of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
Measured: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Number of patients readmitted to usual care team
The number of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.
Measured: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Percentage of patients readmitted to the PHP team
The percentage of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
Measured: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Percentage of patients readmitted to usual care team
The percentage of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.
Measured: Implementation Phase 1 up to 9 months, Sustained Implementation Phase 2 up to 33 months
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted3 Sep 2024
- Study start9 Jan 2025
- Primary completionJan 2028 (estimated)
- Study completionJan 2028 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for High-need, High-complexityStudies of the same condition, open and under way.
- 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
- 1,200 participants (estimated)
Sponsor and investigators
- Lead sponsor
- University of Wisconsin, Madison
- Sponsor type
- University, hospital or other
- Responsible party
- Sponsor
- Investigators
- Sara Westergaard, MD, MPH, Principal investigator, University of Wisconsin, Madison
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT06581224
- Sponsor's protocol ID
- 2024-1299
- Other IDs
- A534270, Protocol Version 12/23/25
- Acronym
- PHP Team
- Status last verified
- Jan 2026
- First submitted
- 29 Aug 2024
- Last updated
- 26 Jan 2026
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 26 Jan 2026. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- Implementation of a Primary Hospitalist Provider Team to Enhance the Care for High-Need High-Complexity Patients Requiring Hospitalization
- ClinicalTrials.gov ID
- NCT06581224
- Acronym / sponsor ID
- PHP Team / 2024-1299
- Conditions
- High-need, High-complexity
- Study type
- Interventional
- Recruitment status
- Recruiting
- Enrolment
- 1,200 participants (estimated)
- Lead sponsor
- University of Wisconsin, MadisonUniversity, hospital or other
- Study start
- 9 Jan 2025 (actual)
- Primary completion
- Jan 2028 (estimated)
- Study completion
- Jan 2028 (estimated)
- First posted
- 3 Sep 2024 (actual)
- 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.
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.
Detailed description
The overarching goal of this study is to reduce inpatient care fragmentation for high-need, high-complexity (HNHC) patients and improve outcomes by implementing a primary hospital provider (PHP) team. In this study, we will specifically evaluate the feasibility of implementation of this team as well as workforce and operational acceptance, as well as its impact on continuity of hospital medicine care across subsequent admissions.
The study is conducted as a two-arm, pragmatic hybrid type II effectiveness implementation trial with two sequential phases. Phase 1 focuses on initial feasibility and early acceptability of the PHP team. Phase 2 evaluates sustained implementation, reach, and longitudinal continuity outcomes using the same intervention, eligibility criteria, and study procedures. No changes will be made to the intervention, eligibility criteria, or data collection methods between phases.
Study Aims:
Aim 1 Primary Implementation Objective: Compare the fragmentation in hospital medicine care during subsequent admissions for HNHC patients assigned to the PHP team with those continuing to receive usual care.
- Aim 1a (Phase 1): Assess feasibility and early continuity of care during subsequent admissions.
- Aim 1b (Phase 2): Evaluate sustained continuity and re-exposure to the PHP team across repeated hospitalizations over an extended enrollment period.
Aim 2 Primary Exploratory Objective: Explore perceptions of care among HNHC patients and caregivers randomized to the PHP team and to a usual care team.
Aim 3 Secondary Exploratory Objective: Identify operational perceptions of the implementation of the PHP team from a workforce and system-level perspective.
Study design
- Primary purpose
- Health services research
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- None (open label)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| PHP Team | Experimental | Other: Primary Hospital Provider TeamPHP Team |
| Usual Care | No intervention | –Usual Care hospital medicine team |
Who may qualify
- Ages
- 18 years and older
- Sex
- All
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (2 listed)
- 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
Key exclusion criteria (4 listed)
- 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
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 |
|---|---|---|
| Primary Hospital Provider TeamThe 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. | Other | PHP Team |
Primary outcome
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
The number of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
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
The number of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.
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
The percentage of patients in the PHP arm who were readmitted to the PHP team on subsequent hospitalizations.
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
The percentage of patients in the usual care arm who were readmitted to a usual care team on subsequent hospitalizations.
Results and safety
This study is still under way. Results are not available in the source record yet.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 26 Jan 2026.
- Individual participant dataSharing planned: No
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.
Sara Westergaard, MD, MPH principal investigator
University of Wisconsin, Madison
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A study testing Primary Hospital Provider Team in people with High-need, High-complexity, run by University of Wisconsin, Madison at 1 site in United States.
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 2 inclusion and 4 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: looking for participants now, as of the sponsor's last update on 26 Jan 2026. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in United States. 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?
This study is still under way. Results are not available in the source record yet.
How can a doctor refer a patient or contact the research team?
Contact Sara Westergaard, MD, MPH (608-261-1150, swesterga@medicine.wisc.edu), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the 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). The study lists 4 primary outcomes in all. It is what the study was designed to measure, not a finding.
Where can I read the original study information?
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 26 Jan 2026; AzTrials last refreshed its copy on 26 Oct 2026.