Improving Care Transitions for Medicaid Insured Individuals With Co-occurring Serious Mental Illness

This study is looking at a program called the THRIVE Clinical Pathway, which helps Medicaid-insured individuals, including those with serious mental illness, after they've been in the hospital. The goal is to see if THRIVE helps people transition back home smoothly. Researchers will compare how often people referred to homecare, how many are readmitted to the hospital within 30 days, and how many visit the emergency room within 30 days, for those using THRIVE versus those receiving standard care. You might be able to join if you are 18 or older, have Medicaid insurance, live in Pennsylvania, were recently hospitalized at the study hospital, and agree to home care with a partner home care setting. The study is currently unclear on its recruitment status.

Study design
This study is an interventional study that plans to enroll 267 participants. It uses a mixed-methods approach, combining quantitative data (numbers) with qualitative data (interviews) to understand the THRIVE program.
What's involved
Not specified in the trial record.
Compensation
Not stated in the trial record.
Follow-up
Participants' rates of readmissions and emergency department visits will be measured 30 days following hospital discharge. Rates of referrals to homecare will be measured through study completion, an average of 18 months.

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NCT06203509

Improving Care Transitions for Medicaid Insured Individuals With Co-occurring Serious Mental Illness

Recruiting
NAAges 18+InterventionalTreatment
University of Pennsylvania
~267 participants
Updated 2026-08-12 on ClinicalTrials.gov
What's tested:Thrive Intervention

At a glance

Recruiting sites
1 of 1 listed site is recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
Rates of Referrals to Homecare
Measured over Through study completion, an average of 18 months
+3 more outcomes measured
Care Transitions

NCT06203509

Where you'd take part

This study runs at 1 site. They're the same protocol — you choose where, and that choice sets who your contact draft is addressed to.

  • Upenn School of Nursing Centre For Health Outcomes Policy Research

    Philadelphia, Pennsylvaniastudy coordinator listed

    Recruiting

Sites open and close at different times, so the status above is per site — it can differ from the study's overall status.

  • Jacqueline M Brooks Carthon, PhD,RN · PRINCIPAL_INVESTIGATOR · University of Pennsylvania
Jacqueline M Brooks Carthon, PhD,RN
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Eligibility criteria

Inclusion

Medicaid insured
Residing in the state of Pennsylvania
Experienced a hospitalization at study hospital
Agrees to home care at partner home care setting.

Exclusion

Individuals under age 18
  • Rates of Referrals to HomecareThrough study completion, an average of 18 months

    We will evaluate changes in home care referrals between case managers exposed to the intervention compared to those who were not

  • Rates of Readmissions30 days following hospital discharge

    We will evaluate the rate of readmissions over the course of the study for THRIVE participants compared to those receiving usual care

  • Rates of Emergency Department Visit30 days following hospital discharge

    We will evaluate the rate of ED visits over the course of the study for THRIVE participants compared to those receiving usual care.

  • Primary Care or Specialist Visit30 Days following hospital discharge

    We will compare the rates of primary care provider and specialist visits within 30 days following discharge compared to those receiving usual care