Status:
RECRUITING
Care Transitions App for Patients With Multiple Chronic Conditions
Lead Sponsor:
Brigham and Women's Hospital
Collaborating Sponsors:
Agency for Healthcare Research and Quality (AHRQ)
Conditions:
Heart Failure
Congestive Heart Failure
Eligibility:
All Genders
55+ years
Phase:
NA
Brief Summary
The objective of this study is to widely implement and evaluate the Care Transitions App in a randomized controlled trial. The app the investigators designed for patients with multiple chronic conditi...
Detailed Description
Care transitions are a vulnerable period for patients, leading to a 20% rate of readmissions, 11% rate of post-discharge adverse drug events, 15% rate of falls, and 29% rate of total post-discharge ad...
Eligibility Criteria
Inclusion
- Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit
- Discharging to home, home health care service or assisted living
- Fluent in spoken English in patient or healthcare proxy
- Patients with at least one of the conditions listed below + one additional chronic condition on the problem list.
- Patient with heart failure on the problem list
- Patient with type 2 diabetes on the problem list
- Patient with chronic kidney disease on the problem list
Exclusion
- Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit
- Pregnant
- Prisoner, institutionalized individual or in police custody
- Discharge planned within 3 hours of screening
- Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia
- Not fluent in spoken English in patient and health proxy
- Unlikely to be discharged to home
- Lacks a device capable of accessing the app
- Lack of a working telephone for 30-day follow-up
Key Trial Info
Start Date :
October 8 2024
Trial Type :
INTERVENTIONAL
Allocation :
ESTIMATED
End Date :
December 1 2026
Estimated Enrollment :
798 Patients enrolled
Trial Details
Trial ID
NCT06051058
Start Date
October 8 2024
End Date
December 1 2026
Last Update
November 13 2025
Active Locations (1)
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1
Brigham and Women's Hospital
Boston, Massachusetts, United States, 02120