Implementation of a Primary Hospital Provider team to improve patient care
Official title: Implementation of a Primary Hospitalist Provider Team to Enhance the Care for High-Need High-Complexity Patients Requiring Hospitalization
Run by University of Wisconsin, Madison · NCT06581224 · Data updated 2026-11-12
This study is testing whether having a dedicated Primary Hospital Provider team can help patients with complex health needs get better care and fewer hospital visits.
Quick facts
| Study type | Interventional |
|---|---|
| Ages | 18 Years and up |
| Sex | All |
| Enrollment | 1200 (estimated) |
| Sponsor | University of Wisconsin, Madison Academic / other |
| Drugs / interventions | chemotherapy, immunotherapy |
| Locations | 1 site (Madison, Wisconsin) |
| Status | Recruiting |
| Started | January 9, 2025 |
| Main results expected | January 2028 |
| Study ends | January 2028 |
| Registry record updated | January 26, 2026 |
| Trial ID | NCT06581224 on ClinicalTrials.gov |
Is this trial a fit for you?
✓Likely a good fit
Ideal candidates are adults over 18 who have had two or more hospitalizations in the past year and have a high readmission risk score.
✕Probably not a fit
Patients currently receiving chemotherapy or immunotherapy, those with specific outpatient primary care arrangements, prisoners, and pregnant women may not benefit from this study.
A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.
What this trial studies
This clinical trial aims to implement a Primary Hospital Provider (PHP) team to enhance continuity of care for patients with high needs and complexity who are frequently hospitalized. The study will compare outcomes for patients assigned to the PHP team with those receiving usual care, focusing on whether patients are more likely to be assigned to the PHP team during follow-up hospitalizations. Additionally, some participants will be interviewed to gather insights on their experiences and care needs. The goal is to determine the effectiveness of the PHP team in improving patient care.
Why it matters
Potential benefit: If successful, this approach could lead to improved care continuity and better health outcomes for frequently hospitalized patients.
How similar studies have gone: While similar approaches have been explored, this specific implementation of a PHP team is novel and has not been extensively tested.
Who can join: the full rules
Show full inclusion / exclusion criteria
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
Where it's running
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UW Hospital and Clinics
Madison, Wisconsin, United States Recruiting
Study contacts
- Principal investigator: Sara Westergaard, MD, MPH — University of Wisconsin, Madison
- Study coordinator: Sara Westergaard, MD, MPH
- Email: swesterga@medicine.wisc.edu
- Phone: 608-261-1150
How to take part
- Review the eligibility criteria above with your treating physician.
- Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
- Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.