Testing a Nurse-led Phone-Based Program to Help Older Veterans Recover Function After Hospital Stay

What this Trial Is About

Functional decline after hospitalization is a major concern for older Veterans, often leading to loss of independence and disability. This research aims to develop and test a new version of the VAs nurse-led Coordinated Transitional Care CTraC program, called CTraC-FIT, which focuses on functional recovery. The study addresses the gap in current care by integrating functional assessment and intervention strategies to help Veterans regain and maintain their independence after leaving the hospital. Participants will be randomly assigned to one of two groups the CTraC-FIT intervention group or the Enhanced Usual Care group. The CTraC-FIT group receives a structured transitional care program led by a nurse case manager via phone or video, including follow-up calls, health coaching, and care coordination. The usual care group continues with standard medical care provided by their assigned VA healthcare teams, with additional assessments and safety protocols if needed. The study involves a 30-day intervention period with follow-up assessments at the end of the intervention and three months later. During the study, participants will complete surveys and interviews to assess the feasibility and acceptability of the intervention. Researchers will measure physical, cognitive, and social function, as well as quality of life, through self-reports and performance tests at the start, after 30 days, and at 3 months. The study also tracks enrollment, recruitment, retention, adherence, and protocol fidelity to understand how well the intervention and study procedures work. Total participation lasts at least three months, with close monitoring during and after the intervention period.

Development and Feasibility of CTraC-FIT