Care Transitions App for Patients With Multiple Chronic Conditions

What this Trial Is About

Researchers are evaluating the Care Transitions App in a randomized controlled trial to support patients with multiple chronic conditions such as diabetes, congestive heart failure, and chronic kidney disease. The study addresses the high rates of readmissions, adverse drug events, falls, and other complications that often occur after hospital discharge. The goal is to improve communication and simplify care plans to help patients and caregivers manage complex medication regimens and fall prevention strategies during this vulnerable period. The trial compares the use of the Care Transitions App against usual care for patients discharged from hospital. The app includes four key parts: falls-reduction content; a digital post-discharge care plan covering education, medications, follow-up appointments, warning signs, nutrition, and other care activities; condition-specific care plans for patients with multiple chronic conditions; and a post-discharge report module that summarizes key findings and allows patients to enter notes, questions, and recovery goals. Participants will use the app after hospital discharge to support their care transition. Participants aged 55 and older with multiple chronic conditions will be enrolled and followed for 30 days after discharge. Researchers will assess the effect of the app on post-discharge adverse events and 30-day readmission rates. Study activities include monitoring health outcomes and follow-up contacts by phone. Participants must have access to a device capable of using the app and a working telephone. The total study duration for each participant covers the discharge period and 30 days of follow-up to measure outcomes.

Care Transitions App for Patients With Multiple Chronic Conditions