Supporting Older Adults Transition From Hospital to Home Using AI-Based Digital Monitoring and Personalized Assistance to Reduce Readmission Risk

What this Trial Is About

Researchers are evaluating a digital remote monitoring system designed to reduce the risk of hospital readmission within 30 days for elderly patients with multiple health conditions. This pilot study takes place across three sites in Italy, Romania, and Norway, enrolling 210 adults aged 65 and older. The goal is to develop a digital ecosystem that identifies and prevents the risk of readmission after hospital discharge. Participants are randomly assigned to one of two groups. One group receives the TRANSCARE digital remote monitoring ecosystem, which includes home medical devices to measure vital signs, a wearable activity tracker, and a telemonitoring software platform. They use these tools daily for 90 days after discharge alongside standard post-discharge care. The other group receives only the usual care provided by their national healthcare system without the digital tools. Throughout the study, participants are monitored for readmission rates at 30, 60, and 90 days after discharge. Researchers also assess changes in physical performance, platform usability, psychosocial effects of technology, and digital health literacy at different time points. This comprehensive monitoring helps evaluate the effectiveness of the digital system and supports participant self-management during the 90-day follow-up period.

New Care Pathways for Supporting TRANSitional CARE From Hospital to Home Using AI and Personalized Digital Assistance