Study of a Care Transitions App for Adults 55 and Older with Multiple Chronic Conditions Including Diabetes, Heart Failure, and Kidney Disease

What this Trial Is About

This research aims to evaluate the use of a Care Transitions App designed to support patients with multiple chronic conditions MCC such as diabetes, congestive heart failure, and chronic kidney disease during the vulnerable period after hospital discharge. The study addresses common challenges like complex medication regimens, poor communication among care teams, and risks of falls and adverse events that often lead to readmissions and complications for these patients. Participants will be randomly assigned to either use the Care Transitions App or receive usual care after hospital discharge. The app includes modules to help reduce falls, provide a digital post-discharge care plan, offer condition-specific symptom management, and allow patients to track recovery goals and communicate with providers. The study will take place in an academic medical center and primary care clinics. During the study, participants will be monitored for 30 days after discharge to assess adverse events and readmission rates. Data collected will help determine the apps impact on post-discharge safety and care management. Participants need access to a device to use the app and will be followed up by telephone to support study assessments and outcome measurements.

Care Transitions App for Patients With Multiple Chronic Conditions