Actively Recruiting
Care Transitions App for Patients With Multiple Chronic Conditions
Led by Brigham and Women's Hospital · Updated on 2025-11-13
798
Participants Needed
1
Research Sites
112 weeks
Total Duration
On this page
Sponsors
B
Brigham and Women's Hospital
Lead Sponsor
A
Agency for Healthcare Research and Quality (AHRQ)
Collaborating Sponsor
AI-Summary
What this Trial Is About
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 conditions has four envisioned modules: 1) falls-reduction content, 2) a digital post-discharge transitional care plan (e.g., after hospital care plan, including education, medications, follow-up appointments, warning signs to watch for, nutrition, and other care plan activities), 3) a new module for patients with MCC (diabetes, congestive heart failure, and chronic kidney disease) including condition-specific post-discharge care plans with relevant symptom management activities, 4) a new post-discharge report module which summarizes key care transition findings and allows for patients to enter notes and questions for their providers and their own goals for recovery.
CONDITIONS
Official Title
Care Transitions App for Patients With Multiple Chronic Conditions
Who Can Participate
Eligibility Criteria
You may qualify if you...
- Adult patients 55 years or older with a Brigham primary care provider or appointment in one of 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
- Have at least one of the following conditions plus one additional chronic condition on the problem list: heart failure, type 2 diabetes, or chronic kidney disease
You will not qualify if you...
- Adult patients 55 years or older with Westwood, Pembroke, or Transition Clinic primary care providers admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other specialty units
- Pregnant
- Prisoner, institutionalized individual, or in police custody
- Discharge planned within 3 hours of screening
- Too ill to participate or have active psychosis, serious mental illness, delirium, or severe dementia
- Not fluent in spoken English in patient and healthcare proxy
- Unlikely to be discharged to home
- Lack a device capable of accessing the app
- Lack a working telephone for 30-day follow-up
AI-Screening
AI-Powered Screening
Complete this quick 3-step screening to check your eligibility
Trial Site Locations
Total: 1 location
1
Brigham and Women's Hospital
Boston, Massachusetts, United States, 02120
Actively Recruiting
Research Team
L
Lipika Samal, MD, MPH
CONTACT
P
Patricia Dykes, PhD
CONTACT
How is the study designed?
Study Type
INTERVENTIONAL
Masking
NONE
Allocation
RANDOMIZED
Model
PARALLEL
Primary Purpose
SUPPORTIVE_CARE
Number of Arms
2
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