A Stepped-Wedge Cluster-Randomized Trial to Increase Home Health Referrals for Medicaid-Insured Patients: The Thrive Trial

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BACKGROUND: Medicaid-insured individuals and those dually eligible for Medicare and Medicaid face high rates of adverse post-hospital outcomes, driven in part by fragmented care transitions and unmet social needs. Despite evidence supporting the use of home health services post-hospitalization, fewer than 20% of Medicaid-insured patients receive a referral. Thrive is an evidence-based transitional care model designed to improve post-discharge care for Medicaid-insured adults and duals by integrating traditional home health services with enhanced social and clinical support. OBJECTIVE: To examine whether implementing Thrive increased the number of patients referred to home health services by discharge planners and to evaluate the acceptability, appropriateness, and feasibility of Thrive and implementation strategy helpfulness. DESIGN: 24-month type 1 hybrid effectiveness-implementation stepped-wedge cluster-randomized trial among discharge planners working on medicine services at a single hospital in the northeastern United States. PARTICIPANTS: 14 discharge planners. INTERVENTION: Discharge planners were randomly assigned a date to begin Thrive referrals. They received initial training, bi-weekly reminders during their intervention step, and monthly clinical updates after all planners became actively involved in referrals. MAIN MEASURE: The primary outcome was referral to home health services. Secondary outcomes included acceptability, appropriateness, and feasibility of Thrive and helpfulness of implementation strategies. KEY RESULTS: Discharge planners who were trained to refer to Thrive were nearly twice as likely to make a home health referral compared to those who were not trained (OR = 1.98; 95% CI: 1.32-2.98; p = .001). Planners found Thrive to be acceptable, appropriate, and feasible, and rated in-person training and reminders from their manager the most helpful implementation strategies. CONCLUSIONS: The introduction of the Thrive transitional care program increased home health referrals. Expanding the use of home health services for Medicaid-insured individuals and duals has the potential to enhance care transitions and improve the quality of life following a hospital discharge. TRIAL REGISTRATION: ClinicalTrials.gov NCT05714605, date of registration: 2/6/2023; https://clinicaltrials.gov/ct2/show/NCT05714605.

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