Clinical trials: Transitional Care Planning
Type 2 Diabetes Mellitus, Cardiometabolic Conditions
Mi Puente: My Bridge to Better Cardiometabolic Health and Well-Being
Mi Puente (or "My Bridge") is a culturally-tailored, interdisciplinary approach designed to support at-risk Hispanic patients and their caregivers pre- and post-hospital discharge as they navigate the multi-level barriers that…
- Conditions
- Type 2 Diabetes Mellitus, Cardiometabolic Conditions, Behavioral Health Concerns
- Trial name
- Mi Puente (NCT02723019)
- Testing
- Volunteer Peer Mentor+Behavioral Health Nurse
- Where
- United States
- Volunteers
- 536 people
- Sponsor
- Scripps Whittier Diabetes Institute
Heart Failure
Heart Failure Events Reduction With Remote Monitoring and eHealth Support Investigator Initiated Trial
The primary objective of the study is to evaluate the efficacy of a telemedicine-based follow-up strategy compared with usual care in the management of patients with chronic heart failure (HF) at high risk of clinical events.
- Trial name
- HERMeS (NCT03663907)
- Testing
- Telemonitoring
- Where
- Spain
- Volunteers
- 510 people
- Sponsor
- Hospital Universitari de Bellvitge
Heart Failure, Self-care
mHealth Intervention to Support Self-care During the Hospital to Home Transition in Individuals With Heart Failure
This study is a pilot randomized controlled trial designed to evaluate the feasibility, acceptability, usability, and preliminary efficacy of a mobile health (mHealth) educational self-management intervention for individuals with…
- Conditions
- Heart Failure, Self-care, Transitional Care
- Trial name
- HF-mHealth (NCT07478081)
- Testing
- mHealth Educational Self-Management Application, Usual transitional care
- Where
- Colombia
- Volunteers
- 30 people
- Sponsor
- Universidad de la Sabana
Cognitive Impairment, Dementia
Older Adults With Cognitive Impairment Doing Sit to Stands, Walking in Transitional Care Programs: A Feasibility Study
The goal of this intervention study is to test the effects of a nurse-led mobility intervention (known as the OASIS Walking Intervention (Older Adults performing Sit to Stands and Walking Intervention)) in older adults with…
- Conditions
- Cognitive Impairment, Dementia, Delirium, Functional Decline
- Trial name
- OASIS (NCT06150339)
- Testing
- OASIS Walking Intervention
- Where
- 2 sites in Canada
- Volunteers
- 6 people
- Sponsor
- University Health Network, Toronto
Heart Failure
Caregiver Enhanced Assistance and Support for the Elderly Heart Failure Patient at Hospital Discharge (CEASE-HF)
Close to ninety percent of older heart failure (HF) patients have some cognitive deficits at hospital discharge which may impact their ability to make effective decisions about their healthcare.
- Trial name
- CEASE-HF (NCT01886534)
- Testing
- Standardized Heart Failure Discharge Summary to Primary Care Physicians©, Standardized education sessions, Heart Failure Diuretic Decision Support Tool for Patient Self Management©
- Where
- Canada
- Volunteers
- 78 people
- Sponsor
- McMaster University
Chronic Inflammatory Rheumatic Diseases of Childhood, Juvenile-Onset Chronic Inflammatory Rheumatic Diseases
Compassionate Care and Organization of Healthcare Services for a Successful Transition in Rheumatology
The transition from pediatric to adult care is a critical period for young people with chronic inflammatory rheumatic diseases (CIRD) and is associated with risks of poor self-management, loss to follow-up, and disease worsening.
- Conditions
- Chronic Inflammatory Rheumatic Diseases of Childhood, Juvenile-Onset Chronic Inflammatory Rheumatic Diseases, Transition of Care in Chronic Inflammatory Rheumatic Diseases
- Trial name
- BOOST-R (NCT07469787)
- Where
- France
- Volunteers
- 50 people
- Sponsor
- Assistance Publique - Hôpitaux de Paris
Transitional Care
Enhancing Timely Access to Medication Changes: The Role of Pharmacists in Overcoming Transitions of Care Challenges
Objective: Among patients discharged from the hospital with changes in maintenance prescription medication, how does experiencing a medication access gap compared to a no medication access gap impact the time to first unplanned…
- Trial name
- NCT07018232
- Testing
- Unplanned healthcare encounter
- Where
- United States
- Volunteers
- 104 people
- Sponsor
- The Guthrie Clinic
Diabetes
Bamberg Diabetes Transitional Care Pilot Study
Bamberg County residents who has been diagnosed with or is at high risk for diabetes, may be eligible for a clinical research study to improve diabetes self-management and decrease hospital re-admissions.
- Trial name
- NCT02560090
- Testing
- Surveys, Telephonic Nurse Intervention, In-person Community Health Worker
- Where
- United States
- Volunteers
- 58 people
- Sponsor
- Medical University of South Carolina
Heart Failure, Heart Failure Hospitalization
Teach-Back Discharge Education to Improve Self-Care and Reduce 30-Day Readmissions in Heart Failure Patients
This study aimed to improve how patients with heart failure understand and manage their condition after leaving the hospital. Many heart failure patients are readmitted within 30 days due to confusion about their discharge…
- Conditions
- Heart Failure, Heart Failure Hospitalization, Readmission, Hospital
- Trial name
- NCT07280208
- Testing
- Teach-Back Discharge Education
- Where
- United States
- Volunteers
- 57 people
- Sponsor
- Nova Southeastern University
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
Heart Failure, Acute Heart Failure (AHF)
OPTIMUM Study of Remote Patient Monitoring in Ambulatory Heart Failure Care
Heart failure is a leading cause of hospitalization and readmission, particularly among older adults with multiple comorbidities.
- Trial name
- OPTIMUM (NCT07439081)
- Testing
- Satelia® Cardio Remote Patient Monitoring System
- Where
- France
- Volunteers
- 504 people
- Sponsor
- Médipôle Lyon-Villeurbanne
Chronic Kidney Disease, End-Stage Renal Disease
Medication Intervention in Transitional Care to Optimize Outcomes & Costs for CKD & ESRD
Transitional care strategies focused on enhancing the accuracy and comprehensiveness of medication information transfer will lead to improved health outcomes among hospitalized patients with chronic kidney disease.
- Trial name
- CKD/ESRD-MIT (NCT01459770)
- Testing
- Medication Information Transfer Intervention, Usual care for hospital discharge
- Where
- United States
- Volunteers
- 120 people
- Sponsor
- Providence Medical Research Center
Chronic Opioid Use
VA Transitional Pain Service Study
The VA Community Care Program has provided an important resource to improve access to surgical care for Veterans unable to have treatment at VA Medical Centers (VAMC).
- Trial name
- VATPS (NCT06223503)
- Testing
- Transitional Pain Service
- Where
- United States
- Volunteers
- 400 people
- Sponsor
- VA Office of Research and Development
Patient Admission, Patient Discharge
Combined Social Worker and Pharmacist Transitional Care Program
In an effort to improve care coordination and reduce hospital readmissions, Rush University Medical Center developed the Combined Social Worker and Pharmacist Program, which targets both the psychosocial and clinical risk factors…
- Trial name
- NCT01503554
- Testing
- Combined Social Worker and Pharmacist Program, No Intervention: Usual Care
- Where
- United States
- Volunteers
- 100 people, healthy volunteers welcome
- Sponsor
- Rush University Medical Center
Type 1 Diabetes Mellitus, Obesity
The COCCOS Study: a Transition Program for Young Persons With Chronic Conditions
A study is undertaken to examine the feasibility of the newly developed transition program in adolescents with type 1 diabetes, asthma and obesity in a multicentric setting.
- Conditions
- Type 1 Diabetes Mellitus, Obesity, Asthma
- Trial name
- COCCOS (NCT07145671)
- Testing
- Transition program
- Where
- Belgium
- Volunteers
- 65 people, healthy volunteers welcome
- Sponsor
- Universiteit Antwerpen
Stroke Acute, Stroke (CVA) or Transient Ischemic Attack
Evaluating the Effect of Nurse-Led Stroke Transitional Care in Tanzania
The goal of this observational study is to assess the effects of nurse-led stroke transitional care in stroke survivors, caregivers and healthcare providers who participate in nurse-led stroke transitional care program to improve…
- Trial name
- NCT07319312
- Testing
- Nurse-led stroke transitional care program
- Where
- Tanzania
- Volunteers
- 130 people
- Sponsor
- Shandong University
Type 2 Diabetes Treated With Insulin
Flash CONtinous Glucose Monitoring in TRansition to Outpatient: Libre for Type 2 Diabetes Mellitus (CONTROL-DM)
This is a pilot study of the use of flash glucose monitoring (FGM) to assess glycemic control, behavioural, quality of life benefits and manpower utilization in poorly controlled T2DM patients on insulin in the transitional care…
- Trial name
- CONTROL-DM (NCT04871438)
- Testing
- Flash glucose monitoring
- Where
- Singapore
- Volunteers
- 34 people
- Sponsor
- Woodlands Hospital
Stroke, Transient Ischemic Attack
Comprehensive Post-Acute Stroke Services
The purpose of this pragmatic study is to investigate whether implementation of a comprehensive post-acute stroke service model that integrates Early Supported Discharge (ESD) and Transitional Care Management (TCM) for stroke…
- Trial name
- COMPASS (NCT02588664)
- Testing
- COMPASS Intervention
- Where
- 40 sites in United States
- Volunteers
- 6,024 people
- Sponsor
- Wake Forest University Health Sciences
Chronic Disease, Integrated Care
Implementation of Community-based Collaborative Management of Complex Chronic Patients
Background/Aims: Large scale adoption of integrated care for chronic patients constitutes a key milestone to accelerate adaptation of current healthcare systems to the evolving needs triggered by population ageing and high…
- Conditions
- Chronic Disease, Integrated Care, Telemedicine
- Trial name
- Nextcare_CCP (NCT02956395)
- Testing
- Integrated care intervention
- Where
- Spain
- Volunteers
- 3,000 people
- Sponsor
- Hospital Clinic of Barcelona
Fibrosis
Transitional Care Interventions for Patients With Cirrhosis Post-TIPS
The investigators conducted a randomized controlled trial to describe if multidisciplinary and patient-centered transitional care interventions for patients with cirrhosis post-TIPS can improve compliance behavior and reduce…
- Trial name
- NCT02877953
- Testing
- the prevention of complications post-TIPS
- Volunteers
- 76 people
- Sponsor
- Shihezi University