Status:
RECRUITING
Digital Bridge: Using Technology to Support Patient-centered Care Transitions From Hospital to Home
Lead Sponsor:
Mount Sinai Hospital, Canada
Collaborating Sponsors:
MOUNT SINAI HOSPITAL
Trillium Health Partners
Conditions:
Older Adults With Complex Care Needs
Eligibility:
All Genders
60+ years
Phase:
NA
Brief Summary
Older adults who live with multiple chronic conditions are more likely to experience frequent admissions and discharges from hospital. These transitions are often challenging and leave people at risk ...
Detailed Description
Older adults with multi-morbidity and complex care needs (CCN) are among those most likely to experience frequent care transitions between settings, particularly from hospital to home. Many of these c...
Eligibility Criteria
Inclusion
- Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid).
Exclusion
- Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance.
Key Trial Info
Start Date :
April 15 2023
Trial Type :
INTERVENTIONAL
Allocation :
ESTIMATED
End Date :
March 30 2026
Estimated Enrollment :
640 Patients enrolled
Trial Details
Trial ID
NCT04287192
Start Date
April 15 2023
End Date
March 30 2026
Last Update
October 3 2025
Active Locations (1)
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1
Sinai Health
Toronto, Ontario, Canada, M5G 1X5