Clinical trials: Care Transitions
Health Related Social Needs (HRSN), Pharmacy
Pharmacist-Led SDoH Screening Intervention During Transitions of Care in an Acute Care Setting
The study is a quasi-experimental pilot study conducted at Buffalo General Medical Center (BGMC). It aims to evaluate the feasibility, acceptability, and effectiveness of a pharmacist-led intervention addressing health-related…
- Conditions
- Health Related Social Needs (HRSN), Pharmacy, Medication Reconciliation
- Trial name
- NCT06802393
- Testing
- Intervention
- Where
- United States
- Volunteers
- 58 people
- Sponsor
- State University of New York at Buffalo
Chronic Disease
Home Based Care Transitions Tailored by Cognition and Patient Activation
There is overwhelming evidence that patients with multiple chronic illnesses need better self-management skills. Discharge from the hospital may not be the most opportune time to be teaching patients these self-management skills.
- Trial name
- NCT02045147
- Testing
- Grp 1a Low Cognition, Low Activation Intervention, Grp 2a Low Cognition, High Activation Intervention, Grp 3a Normal Cognition, Low Activation Intervention
- Where
- United States
- Volunteers
- 263 people
- Sponsor
- University of Nebraska
Congenital Heart Defects
Congenital Heart Adolescents: Program of Transition Evaluation Research
The objective of this study is to evaluate the potential role of a cardiology clinic-based educational intervention for 15 to 17 year olds with congenital heart disease (CHD) and their parents, and to determine whether this…
- Trial name
- CHAPTER (NCT01286480)
- Testing
- Clinic-based Educational Intervention
- Where
- Canada
- Volunteers
- 66 people
- Sponsor
- University of Alberta
Prostate Cancer
Efficacy of a Couple-Focused mHealth Symptom Self-management Program
In this study, the investigators propose to test the efficacy of a couple-focused, web-based tailored prostate cancer symptom management program, Prostate Cancer Education and Resources for Couples (PERC) in a randomized clinical…
- Trial name
- NCT03489057
- Testing
- Prostate Cancer Education and Resources for Couples (PERC), usual care plus NCI website
- Where
- United States
- Volunteers
- 560 people, healthy volunteers welcome
- Sponsor
- UNC Lineberger Comprehensive Cancer Center
Aging
Ambient Independence Measures for Guiding Care Transitions
The purpose of this study is to learn more about how to maintain health and independence for seniors by developing tools that collect data constantly from their home.
- Trial name
- AIMs (NCT02566239)
- Testing
- Share activity data with care team
- Where
- United States
- Volunteers
- 96 people, healthy volunteers welcome
- Sponsor
- Oregon Health and Science University
Psychotic Disorder
Mobile After-Care Support App: Pilot RCT
The overall aim of this program of research is to refine and test the feasibility and acceptability of a newly developed mobile device-delivered app, called Mobile After-Care Support (MACS), to improve patients' coping and…
- Trial name
- MACS-RCT (NCT03955250)
- Testing
- Mobile After-Care Support (MACS) app, Mobile app attention control
- Where
- United States
- Volunteers
- 42 people
- Sponsor
- Butler Hospital
Cerebral Palsy
Respiratory Exacerbation Plans for Action and Care Transitions for Children With Severe CP
This study will pilot test a just-in-time (JIT) adaptive intervention to reduce severe respiratory illness, for children with severe cerebral palsy (CP).
- Trial name
- RE-PACT (NCT05292365)
- Testing
- RE-PACT Intervention
- Where
- 2 sites in United States
- Volunteers
- 60 people
- Sponsor
- University of Wisconsin, Madison
Care Transitions, Dementia
CAPABLE Transitions: A Home Health-Based Intervention for the Hospital or Post-Acute Care Facility-to-Home Transition
This clinical study is designed to test the feasibility of a new intervention, CAPABLE Transitions. CAPABLE Transitions is based on the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) intervention designed…
- Trial name
- NCT04460742
- Testing
- CAPABLE Transitions, Home Health Agency Care
- Where
- United States
- Volunteers
- 31 people
- Sponsor
- University of Rochester
Acute Kidney Injury
A Study of Acute Kidney Injury in Care Transitions
This research is being done to develop materials and processes that will help facilitate education and kidney care coordination for AKI survivors.
- Trial name
- NCT05184894
- Testing
- AKI in Care Transitions (ACT) program
- Where
- United States
- Volunteers
- 50 people
- Sponsor
- Mayo Clinic
Cardiovascular Diseases, Cardiac Rehabilitation
Modified Application of Cardiac Rehabilitation for Older Adults
Modified Application of Cardiac Rehabilitation for Older Adults (MACRO) responds to a critical underuse of cardiac rehabilitation in older adults with a coaching model that addresses issues related to aging as a means to better…
- Conditions
- Cardiovascular Diseases, Cardiac Rehabilitation, Transition of Care
- Trial name
- MACRO (NCT03922529)
- Testing
- MACRO-I, Usual Care
- Where
- 3 sites in United States
- Volunteers
- 416 people
- Sponsor
- Daniel Forman, MD
HIV/AIDS, Hospitalization
Re-engagement at Discharge 2
Early post-discharge mortality is high among Zambians living with HIV admitted to the hospital. This may be due to missed opportunities in post-discharge care, such as inadequate follow-up and treatment.
- Conditions
- HIV/AIDS, Hospitalization, Transitions of Care, Opportunistic Infections
- Trial name
- ReCharge2 (NCT05694546)
- Testing
- Community Health Worker Post-Discharge Intervention
- Where
- 2 sites in Zambia
- Volunteers
- 97 people
- Sponsor
- University of Maryland, Baltimore
Polypharmacy, Care Transitions
A Randomized Controlled Trial to Deprescribe for Older Patients With Polypharmacy
This randomized, controlled trial will evaluate the effects of an intervention to reduce exposure to medications among hospitalized older adults discharged to skilled nursing facilities (SNFs).
- Conditions
- Polypharmacy, Care Transitions, Geriatric Syndromes
- Trial name
- Shed-Meds (NCT02979353)
- Testing
- Shed-Meds: A Patient-Centered Deprescribing Intervention
- Where
- United States
- Volunteers
- 372 people
- Sponsor
- Vanderbilt University Medical Center
Alzheimer Disease or Associated Disorder
Coordinated Emergency Department Transitions
The goal of this observational study is to learn the feasibility, acceptability, appropriateness, and adherence to a case management intervention.
- Trial name
- NCT06933849
- Testing
- Structured case management
- Where
- United States
- Volunteers
- 1,376 people
- Sponsor
- Brown University
Care Transitions
Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at…
- Trial name
- ACHIEVE (NCT02354482)
- Testing
- Patient Communication and Care Management, Home-Based Trust, Plain Language, and Coordination, Hospital-Based Trust, Plain Language, and Coordination
- Where
- United States
- Volunteers
- 7,939 people
- Sponsor
- Mark Williams
ED Patients With Chronic Medical Illnesses
An Emergency Department-To-Home Intervention to Improve Quality of Life and Reduce Hospital Use
The purpose of this study is to determine if assigning older, chronically ill patients a healthcare coach after they leave the Emergency Department (ED) improves their quality of life and reduces the need for hospital-based care.
- Trial name
- NCT02079987
- Testing
- ED-to-home care transition intervention, Usual Care
- Where
- 2 sites in United States
- Volunteers
- 1,101 people
- Sponsor
- University of Florida
HIV, Hepatitis C
Criminal Justice Coordinated Transitional Care
This project aims to enroll 220 incarcerated individuals living with HIV, Hepatitis C (HCV), or history of substance misuse preparing for release into a pilot implementation study to test the feasibility and acceptability of an…
- Conditions
- HIV, Hepatitis C, Substance Use Disorders
- Trial name
- CJC-TraC (NCT05376371)
- Testing
- CJC-TraC
- Where
- 2 sites in United States
- Volunteers
- 219 people
- Sponsor
- University of Wisconsin, Madison
Standard Treatment Versus Engagement Focused Treatment
Improving Transitional Care Experiences in Mental Health
The cost of serious mental illness (SMI) in the U.S. is $317 billion annually. This translates to more than $1000 for every man, women, and child in the U.S. Hospitalization and Emergency Room (ER) visits have the highest costs.
- Trial name
- NCT02213198
- Testing
- Engagement focused care, Standard Care
- Where
- United States
- Volunteers
- 465 people
- Sponsor
- The University of Texas Health Science Center at San Antonio
Transitional Care, Caregivers
Connect-Home Clinical Trial
This study will test whether transitional care targeting care needs of seriously ill, skilled nursing facility (SNF) patients and their caregivers will help to improve SNF patient outcomes (preparedness for discharge, quality of…
- Conditions
- Transitional Care, Caregivers, Patient Discharge, Aging
- Trial name
- NCT03810534
- Testing
- Connect-Home
- Where
- United States
- Volunteers
- 654 people
- Sponsor
- University of North Carolina, Chapel Hill
Hospitalized Patients
Supplement to Hospital to Home Outcomes
Post-discharge nurse phone call
- Trial name
- Supplement (NCT03224130)
- Testing
- Nurse Phone Call, Standard of Care
- Where
- United States
- Volunteers
- 966 people
- Sponsor
- Children's Hospital Medical Center, Cincinnati
Emergencies, Aging
Paramedic Coached ED Care Transitions to Help Older Adults Maintain Their Health
The emergency department (ED) is a common source of acute illness care for older adults. Many older adults who are discharged home from the ED return within 30 days due to numerous challenges faced during the ED-to-home…
- Trial name
- NCT02520661
- Testing
- Care Transitions Intervention
- Where
- 2 sites in United States
- Volunteers
- 1,979 people
- Sponsor
- University of Wisconsin, Madison