Clinical trials: Transitional Care Planning
Asthma in Children, Transplantation
Digital Delivery of Person-centered Transitional Care
Advances in medical care have extended the life expectancy of individuals with congenital and pediatric-onset diseases, leading to an increased need for effective transition programs as these individuals move from pediatric to…
- Trial name
- DigiStep (NCT06823622)
- Testing
- Stepstones transition program
- Where
- 2 sites in Sweden
- Volunteers
- 100 people
- Sponsor
- Göteborg University
Patient Admission, Patient Discharge
Enhanced Discharge Planning Program -- Prospective
The Enhanced Discharge Planning Program (EDPP) is an intervention designed to help older adults safely transition to the community after discharge.
- Trial name
- EDPP (NCT01378234)
- Testing
- Enhanced Discharge Planning Program transitional care
- Where
- United States
- Volunteers
- 740 people
- Sponsor
- Rush University Medical Center
Hospitalization
Assessment of a Medication Reconciliation Program on Transitional Care
The purpose of this study is to assess and compare the effectiveness of the Kaiser Permanente Colorado's (KPCO) Call Center's Medication Reconciliation Program and standard care in regards to their impacts on emergency department…
- Trial name
- NCT00462059
- Testing
- Treatment
- Where
- United States
- Volunteers
- 200 people
- Sponsor
- Kaiser Permanente
Adolescent HIV Infection, Transition to Adult Care
Scale-up of an Evidence-based Adolescent Transition Package to Support Transitional Care Among Youth Living With HIV
Ending the HIV epidemic for youth living with HIV will require implementation and optimization of evidence-based interventions that address barriers to treatment.
- Conditions
- Adolescent HIV Infection, Transition to Adult Care, Implementation Science, Implementation Strategies
- Trial name
- ATTACH-Scale (NCT06924073)
- Testing
- ATP-Youth Enhanced Strategy (ATP-YES)
- Where
- 25 sites in Kenya
- Volunteers
- 1,920 people, healthy volunteers welcome
- Sponsor
- University of Washington
Heart Failure
Impact of Socio Economic Limitations on Health Outcomes in Patients With Recent Admission for Heart Failure
To assess the impact of the socio-economic level on the effectiveness of a comprehensive multidisciplinary program of transitional care for crhonic heart failure patients (primary objective); to analyze this specifically in the…
- Trial name
- SELENE (NCT04022122)
- Testing
- Usual Care follow-up in a heart failure program.
- Where
- Spain
- Volunteers
- 121 people
- Sponsor
- Hospital Universitari de Bellvitge
Comorbidity, Depressive Symptoms
Community Assets Supporting Transitions (CAST)
The aim of this study is to test a support program for older adults with symptoms of depression and other chronic health problems after they are discharged home from hospital.
- Trial name
- CAST (NCT03157999)
- Testing
- Intervention group (CAST)
- Where
- 4 sites in Canada
- Volunteers
- 127 people
- Sponsor
- McMaster University
Heart Failure and Reduced Ejection Fraction, Transitional Care
Effects of a Transitional Care Program on Depression, Self-Efficacy, and Self-Care in Patients With Heart Failure
This randomized controlled trial aims to evaluate the effects of a structured transitional care program on depression, self-efficacy, and self-care behaviors in patients with heart failure.
- Trial name
- NCT07660237
- Testing
- Structured Transitional Care Program, Usual Care
- Where
- Taiwan
- Volunteers
- 130 people
- Sponsor
- Chang Gung Memorial Hospital
Sepsis
Electronic Health Record-Integrated Patient-Generated Data
The purpose of this study is to find out if patients that receive supportive messaging with response adaptation are more likely to adhere to patient-generated data collection and electronic health record integration, compared to…
- Trial name
- NCT06668870
- Testing
- Supplemental Text Messaging, Education and Training for Patient-Generated Data
- Sponsor
- Wake Forest University Health Sciences
Ambulatory Care Sensitive Conditions
Impact of Pharmacist-led Care Navigation Mediated by Digital Health Tools on Hospital Readmissions
Hospitalizations for Primary Care-Sensitive Conditions (PCSCs) are potentially avoidable hospital admissions that may be prevented when Primary Health Care provides effective and timely care through prevention, early diagnosis…
- Trial name
- NCT07789353
- Testing
- Pharmacist-led teleconsultations
- Where
- Brazil
- Volunteers
- 3,220 people
- Sponsor
- Hospital de Clinicas de Porto Alegre
Cystic Fibrosis
Transition From Pediatric to Adult Cystic Fibrosis Care Center
The main objective of register-SAFETIM is to assess the impact of the transition from pediatric to adult cystic fibrosis care center on changes in lung function and nutritional status of patients.
- Trial name
- SAFETIM RNM (NCT02790879)
- Testing
- Transition pediatric - adult
- Where
- France
- Volunteers
- 300 people
- Sponsor
- Hospices Civils de Lyon
Children with Medical Complexity
Bridging Hospital to Home for Children with Medical Complexity and Their Families
The goal of this observational study is to evaluate an innovative pediatric transitional care unit called the Jeroen Pit Huis (JPH).
- Trial name
- BRIDGE (NCT06599398)
- Testing
- Jeroen Pit Huis
- Where
- Netherlands
- Volunteers
- 150 people
- Sponsor
- Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)
Heart Failure, Self Care
Effect and Cost Effectiveness of a Dyadic Empowerment-based Heart Failure Management Program for Self-care
Global population aging has drastically increased healthcare spending worldwide, with the greatest portion going to hospital and community health services.
- Conditions
- Heart Failure, Self Care, Empowerment, Transitional Care
- Trial name
- NCT05806606
- Testing
- Dyadic empowerment based heart failure management program, Dyadic education program
- Where
- Hong Kong
- Volunteers
- 232 people
- Sponsor
- The University of Hong Kong
Functional Impairment, Functional Performance
Development and Feasibility of CTraC-FIT
Functional decline after hospitalization is a serious concern for older Veterans, often leading to loss of independence and disability.
- Trial name
- CTraC-FIT (NCT07132944)
- Testing
- CTraC-FIT, Enhanced Usual Care
- Where
- United States
- Volunteers
- 40 people
- Sponsor
- VA Office of Research and Development
Transitional Care Coordination, Home Visits
Collaborative Home Visits to Reduce Hospital Readmissions and Improve Medication Use During Transitions of Care
The primary objective is to develop a sustainable practice model emphasizing home visits by a collaborative physician and pharmacist team to decrease unplanned emergency department visits and hospital readmissions at 30 and 90…
- Trial name
- NCT02087072
- Testing
- Collaborative visit with provider and pharmacist
- Where
- United States
- Sponsor
- Ohio State University
Medication Reconciliation
Medication Reconciliation Technology to Improve Quality of Transitional Care
This study addresses the problem of inadequate medication reconciliation as patients cross boundaries between inpatient and outpatient care (ambulatory care).
- Trial name
- MedMatch (NCT01195051)
- Testing
- Electronic medication reconciliation
- Where
- United States
- Volunteers
- 4,818 people
- Sponsor
- Indiana University
Pathologic Processes
Adapting Connect-Home Transitional Care for the Unique Needs of Persons With Alzheimer's Disease and Other Dementias and Their Caregivers
This primary purpose of this study will be to (1) examine the feasibility and acceptability of transitional care focusing on care needs of skilled nursing facility (SNF) patients with dementia and their caregivers (primary aim).
- Trial name
- NCT05887388
- Testing
- Connect-Home Plus
- Where
- United States
- Volunteers
- 38 people
- Sponsor
- University of North Carolina, Chapel Hill
Chronic Heart Failure
Implementation and Evaluation of Hospital-to-Home Transitional Care Intervention in Patients with Chronic Heart Failure
This study lasted for a total of three months. The purpose is to build a hospital-family transitional nursing intervention program for patients with chronic heart failure, and to explore the effectiveness of the program on the…
- Trial name
- NCT06779227
- Testing
- Hospital family transitional nursing intervention
- Where
- China
- Volunteers
- 60 people
- Sponsor
- Zhi-fen Feng
Transitional Care
Pharmacist-Led Transition of Care Program in the Emergency Department (Pharm TOC-ED): A Pilot Trial
When patients leave the emergency department, mistakes with their medications are common and can lead to complications or hospital readmissions.
- Trial name
- PharmTOC-ED (NCT07310199)
- Testing
- Multi-faceted pharmacist-led transition of care (ToC) program
- Where
- Qatar
- Volunteers
- 82 people
- Sponsor
- Dr. Muhammad Abdul Hadi
Drug Use
Clinical Pharmacist Intervention to Reduce Drug-related Readmissions Among Older People
This randomized controlled trial primarily investigates if a clinical pharmacist intervention can reduce drug-related readmissions among patients >75 years. The intervention targets the transfer between hospital and primary care.
- Trial name
- NCT03671629
- Testing
- Enhanced clinical pharmacist service
- Where
- Sweden
- Volunteers
- 700 people, healthy volunteers welcome
- Sponsor
- Umeå University
Complex Care, Post-Acute Care Utilization
Comprehensive Enhanced Care Management Under CalAIM for High-Risk Medi-Cal Members
This pragmatic, cluster-randomized trial will evaluate whether a comprehensive CalAIM-aligned care model consisting of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential care…
- Conditions
- Complex Care, Post-Acute Care Utilization, Housing Instability, Residential Care Transition
- Trial name
- COMPASS-CalAIM (NCT07587073)
- Testing
- Comprehensive CalAIM Care Bundle, Usual CalAIM Service Delivery
- Where
- United States
- Volunteers
- 1,200 people
- Sponsor
- StratiHealth