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Implementation of a Primary Hospital Provider (PHP) Team

Implementation of a Primary Hospitalist Provider Team to Enhance the Care for High-Need High-Complexity Patients Requiring Hospitalization

Who can join

Ages 18 and older · All sexes

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

About the study

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.

What is being tested

• Primary Hospital Provider Team (other)

Sponsor: University of Wisconsin, Madison · Participants: 1,200 · Started: Jan 9, 2025

Contact the study team

• Sara Westergaard, MD, MPH · Phone: 608-261-1150

Official record on ClinicalTrials.gov — NCT06581224

Locations in the U.S.

From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.