Clinical trials: Post-discharge Care Transitions
Health Services Research, Prisons, Delivery of Health Care, Vulnerable Populations, Community Health Aides
Evaluation of Transitions Clinic: A Post-Release Clinic for Recently Released Parolees With Chronic Medical Conditions
The purpose of this study is to study the effectiveness of the Transitions Clinic, a post-release clinic for parolees with chronic medical conditions, in achieving increased primary care engagement, lower rates of inappropriate…
- Trial name
- NCT01179035
- Testing
- Transitions Clinic - parolee-targeted care, Expedited Primary Care
- Where
- United States
- Volunteers
- 150 people
- Sponsor
- Transitions Clinic
Acute Kidney Injury, Acute Kidney Injury (AKI)
COordiNated CommuNication, Education, and Care Transitions After Acute Kidney Injury (CONNECT-AKI)
The goal of this clinical trial is to learn whether different ways of providing information and follow-up support after acute kidney injury, also called AKI, can improve care transitions for adults being discharged from the…
- Trial name
- CONNECT-AKI (NCT07626268)
- Testing
- AKI Discharge Summary Template, Chat-Based Educational Messaging Program
- Where
- 2 sites in United States
- Volunteers
- 160 people
- Sponsor
- Northwell Health
Type 2 Diabetes, Medication Adherence
MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients
This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital.
- Conditions
- Type 2 Diabetes, Medication Adherence, Care Transition, Medication Discrepancy
- Trial name
- MEDBRIDGE (NCT07599852)
- Testing
- MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention
- Where
- 2 sites in United States
- Volunteers
- 45 people
- Sponsor
- University of Alabama at Birmingham
Hospitalism
Community Health Worker Care Transitions Study
This study focuses on pairing community health workers (CHWs) with patients that are high risk for readmission prior to hospital discharge in order to assess differences in hospital readmission rates, ED visits, patient…
- Trial name
- CCAT (NCT03085264)
- Testing
- Community Health Worker
- Where
- United States
- Volunteers
- 600 people, healthy volunteers welcome
- Sponsor
- Massachusetts General Hospital
Care Transitions
Testing the Efficacy of a Post-discharge Call Program on the Rate of Readmission
NYU Langone Health patients receive a call from a clinical care coordinator after they are discharged from the hospital (within 1-3 days). The current study is testing the efficacy of this program.
- Trial name
- NCT03683797
- Testing
- Post-discharge call
- Where
- United States
- Volunteers
- 3,267 people
- Sponsor
- NYU Langone Health
Transitions of Care, Patient Portals
Interactive Digital Health Tools to Improve Patient Safety in Acute Care
Study 1: The goal of this study is to implement and evaluate an interactive patient-centered discharge toolkit (PDTK) to engage patients and care partners in discharge preparation and communication with providers after discharge.
- Conditions
- Transitions of Care, Patient Portals, General Medicine, Discharge Checklist
- Trial name
- NCT03116074
- Testing
- Interactive Digital Health Tools
- Where
- United States
- Volunteers
- 750 people, healthy volunteers welcome
- Sponsor
- Brigham and Women's Hospital
Care Transitions
MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care
This study will evaluate a 30-day post-discharge intervention using an automated SMS platform to monitor patients and facilitate communication with their primary care practice.
- Trial name
- MORE-PC (NCT05245773)
- Testing
- Automated SMS program to support post-discharge transitions of care
- Where
- United States
- Volunteers
- 5,000 people
- Sponsor
- University of Pennsylvania
Bipolar Disorder, Major Depression
Effectiveness of mHealth Post-discharge Intervention for Patients With Severe Mental Illness
The overall aim of this program of research is to improve the continuity of care for patients with serious mental illness (SMI) by supporting a safer and more efficient bridge from hospital to outpatient care using a mobile…
- Conditions
- Bipolar Disorder, Major Depression, Schizophrenia
- Trial name
- tFOCUS (NCT05703412)
- Testing
- Transition-FOCUS mHealth Intervention, Check-In
- Where
- United States
- Volunteers
- 180 people
- Sponsor
- Butler Hospital
Traumatic Brain Injury, Caregiver Burden
m-Health Supportive Care Transition Program in Improving Post-Discharged Outcomes
This intervention study aims to investigate the effects of the m-Health supportive care transition program on response patterns (transition stress and the burden of caregiving) among traumatic brain injury (TBI) caregivers and…
- Conditions
- Traumatic Brain Injury, Caregiver Burden, Stress
- Trial name
- NCT05951335
- Testing
- m-Health Transition Care Program
- Where
- Thailand
- Volunteers
- 74 people, healthy volunteers welcome
- Sponsor
- Prince of Songkla University
Appointments and Schedules
Post-Discharge Follow-up Appointment Scheduling
This is a prospective clinical trial evaluating whether a behaviorally informed intervention (pre-discharge iPad video scheduling) increases post-discharge primary care physician (PCP) appointment completion compared to the…
- Trial name
- NCT06387576
- Testing
- Behaviorally informed pre-discharge iPad video scheduling
- Where
- United States
- Volunteers
- 41 people
- Sponsor
- University of California, Los Angeles
Test Result Management
An Automatic Notification System for Test Results Finalized After Discharge
Specific Aims: (Study #1, funded by AHRQ, completed May 2011) 1. To create an automatic notification system to prompt physicians of test results finalized after discharge. 2.
- Trial name
- NCT01153451
- Testing
- Email Notification
- Where
- United States
- Volunteers
- 441 people
- Sponsor
- Brigham and Women's Hospital
Transitions of Care, General Medicine
PREventing Adverse Events Post-Discharge Through Proactive Identification, Multidisciplinary Communication, and Technology
The goal of this study is to expand the use of previously developed patient safety dashboards and patient-centered discharge checklists to three general medicine units in an affiliated community hospital.
- Conditions
- Transitions of Care, General Medicine, Discharge Checklist, Adverse Event
- Trial name
- PREDICT (NCT05232656)
- Testing
- Pre-Discharge Checklist and Patient Safety Dashboard
- Where
- United States
- Volunteers
- 268 people, healthy volunteers welcome
- Sponsor
- Brigham and Women's Hospital
Hospital Readmission, Post-discharge Care Transitions
Evaluating Sequential Strategies to Reduce Readmission in a Diverse Population
Hospital readmissions are common, costly, and potentially preventable. They are also potentially responsive to health system interventions.
- Conditions
- Hospital Readmission, Post-discharge Care Transitions, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease
- Trial name
- NCT01619098
- Testing
- Patient Navigator, Usual care
- Where
- 2 sites in United States
- Volunteers
- 1,510 people
- Sponsor
- Alison Galbraith
Discharge Planning, Emergency Medicine
Use of a Brief Phone Call After ED Discharge
The purpose of this study is to determine whether a phone call from a nurse within 1-3 days after discharge from the Emergency Department (ED) decreases return visits to the ED/ hospital admissions/ death (combined outcome) in…
- Conditions
- Discharge Planning, Emergency Medicine, Geriatrics, Patient Readmission
- Trial name
- NCT01893931
- Testing
- ED Discharge & Medication Call
- Where
- United States
- Volunteers
- 2,003 people
- Sponsor
- University of North Carolina, Chapel Hill
Cardiovascular Diseases
The Impact of a Personalized Care Intervention on 90-day Post-Discharge Care
The purpose of this 90 day study is to demonstrate the extent to which participants with cardiovascular conditions can improve their recovery at home through a mobile app, support and resources made available to them after…
- Trial name
- NCT06146582
- Testing
- Laguna Coach and App Intervention Group
- Where
- United States
- Volunteers
- 187 people
- Sponsor
- Laguna Health, Inc
Critical Illness, Transitions of Care
Evaluating the Effectiveness of an Electronic Medical Transfer Tool to Improve Communication During Transfers From ICU
The transfer of patients from the intensive care unit (ICU) to a medical or surgical hospital ward is a particularly high risk transfer that may expose patients to complications or adverse events if there are communication…
- Trial name
- NCT03590002
- Testing
- Electronic ICU Medical Transfer Tool
- Where
- 4 sites in Canada
- Volunteers
- 1,751 people
- Sponsor
- Henry T. Stelfox, MD PhD
Cancer
Behavioral Coaching Intervention (Laguna Health) for Patients With Cancer
The overall goal of this study is to examine the feasibility, acceptability, and preliminary efficacy of using a behavioral coaching intervention (Laguna Health) for optimizing post-hospital discharge care in patients with…
- Trial name
- LAGUNA (NCT06004141)
- Testing
- Laguna Health
- Where
- United States
- Volunteers
- 18 people
- Sponsor
- Massachusetts General Hospital
HIV, Noncommunicable Diseases
UNCPM 22322 - Adaption of the Transition of Care Model for Post-Discharge HIV-NCD Care in Lilongwe, Malawi - MLATHO
This is an implementation research study that will adapt and pilot test the Transitional Of Care Model (TCM), originally conceived and developed in the USA, for targeted use as a post-discharge intervention for adults…
- Trial name
- MLATHO (NCT06931431)
- Testing
- Transition of Care Model (TCM)
- Where
- Malawi
- Volunteers
- 75 people
- Sponsor
- University of North Carolina, Chapel Hill
Medication Reconciliation
Evaluation of Pharmacist-led Medication Reconciliation Service Benefits in Hospitalised Medical Patients
Background: Transitions of care often lead to medication errors and unnecessary healthcare utilisation. It has been repeatedly shown that medication reconciliation can at least partially reduce this risk.
- Trial name
- NCT06207500
- Testing
- Pharmacist-led Medication Reconciliation
- Where
- Slovenia
- Volunteers
- 553 people
- Sponsor
- The University Clinic of Pulmonary and Allergic Diseases Golnik
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