Clinical trials: Transitions of Care
Adverse Outcomes
Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home
The incidence of drug-induced injury is high in the ambulatory geriatric population, especially for elders with complex healthcare needs during high risk transitions to the ambulatory setting.
- Trial name
- RAMPAGEII (NCT01004328)
- Testing
- Intervention 1: Electronic medical record (EMR)-based transitional care intervention
- Where
- United States
- Volunteers
- 626 people, healthy volunteers welcome
- Sponsor
- University of Massachusetts, Worcester
Chronic Kidney Disease
Healthy Transitions in Late Stage Kidney Disease
Improve health and outcome for people with late stage chronic kidney disease by providing patient centered nursing services in addition to a Nephrologist's routine patient care.
- Trial name
- NCT02085837
- Testing
- Education, Daily weight measurement and monitoring, Universal Dietary education
- Where
- United States
- Volunteers
- 130 people
- Sponsor
- Northwell Health
Diabetes, Hypertension
Pharmacy-led Transitions of Care Intervention to Improve Medication Adherence
Socioeconomically disadvantaged populations with multiple chronic conditions have high rates of nonadherence to essential chronic disease medications after hospital discharge.
- Conditions
- Diabetes, Hypertension, High Cholesterol/Hyperlipidemia, Coronary Artery Disease
- Trial name
- MedAAAction (NCT06374277)
- Testing
- Med AAAction intervention
- Where
- 2 sites in United States
- Volunteers
- 388 people
- Sponsor
- University of Tennessee
Suicide, Suicide, Attempted
Suicide Prevention Among Recipients of Care
Randomized controlled trial to determine the best brief suicide prevention intervention for adults and adolescents who screen positive for suicidal ideation or behavior in emergency departments or primary care clinics.
- Conditions
- Suicide, Suicide, Attempted, Suicidal Ideation, Social Support
- Trial name
- SPARC (NCT04893447)
- Testing
- SPI+, SP+CC (Caring Contacts)
- Where
- United States
- Volunteers
- 1,520 people
- Sponsor
- St. Luke's Health System, Boise, Idaho
Frailty
I4F: Isla for Frailty Feasibility Study
BACKGROUND: Older patients with frailty have complex support needs. How they manage with daily tasks such as eating and drinking, mobilising, communicating their preferences, and the level of support they need, can vary on a…
- Trial name
- I4F (NCT06504641)
- Testing
- Isla for Frailty
- Where
- United Kingdom
- Volunteers
- 95 people
- Sponsor
- Imperial College London
Acute Disease
Improving Safety of Transitions to Skilled Nursing Care Using Videoconferencing
This prospective cohort study seeks to determine if the ECHO-CT program, a healthcare videoconferencing program, can improve clinical outcomes while reducing cost and resource utilization when expanded to a community hospital…
- Trial name
- ECHO-CT (NCT03832257)
- Testing
- ECHO CT Intervention, Matched Non-Participating Facilities
- Where
- United States
- Volunteers
- 10,708 people
- Sponsor
- Beth Israel Deaconess Medical Center
Falls (Accidents) in Old Age
GAPcare: The Geriatric Acute & Post-acute Care Coordination Program for Fall Prevention in the Emergency Department
GAPcare (Geriatric Acute \& Post-acute Care Coordination Program for Fall Prevention) is an early stage investigation that enrolls older adults who present to the Emergency Department after a fall to determine the feasibility of…
- Trial name
- GAPcare (NCT03360305)
- Testing
- GAPcare intervention
- Where
- 2 sites in United States
- Volunteers
- 110 people
- Sponsor
- Rhode Island Hospital
Chronic Obstructive Pulmonary Disease (COPD)
Utility of Remote Lung Auscultation in Transitions of Care After Pulmonary Exacerbations of COPD
Listening to breath sounds with the stethoscope/auscultation is used by pulmonary physicians in conjunction with pulmonary function, signs and symptoms, oxygen saturation and diagnostic testing to admit, follow and discharge…
- Trial name
- NCT05661435
- Testing
- RESP Biosensor
- Where
- 2 sites in United States
- Sponsor
- Strados Labs, Inc.
Transition, Emergencies
The LEARNING WISDOM Phase II Scale up Project
Inspired by the Acute Care for Elders program at Mount Sinai Hospital, this study aims to improve care for elderly patients in four hospitals of Chaudière-Appalaches.
- Conditions
- Transition, Emergencies, Health Care Utilization, Frailty
- Trial name
- NCT04093245
- Testing
- GEM nurse, pre- and post-hospitalization medication list reconciliation, systematic discharge summaries
- Where
- Canada
- Volunteers
- 4,000 people
- Sponsor
- Laval University
Clinical Sepsis
Improving Morbidity During Post-Acute Care Transitions for Sepsis
The purpose of this study is to improve transitions of care for the highest risk, complex patients with suspected sepsis. Atrium Health has developed a nurse-navigator facilitated care transition strategy, called the Sepsis…
- Trial name
- IMPACTS (NCT03865602)
- Testing
- Sepsis Transition And Recovery (STAR), Usual care
- Where
- United States
- Volunteers
- 712 people
- Sponsor
- Wake Forest University Health Sciences
Malignant Solid Neoplasm
Pharmacist-led Transitions of Care in the Outpatient Oncology Infusion Center for Patients With Solid Tumor
This trial studies how well pharmacist-led transitions of care works in the outpatient oncology infusion center for patients with solid tumor.
- Trial name
- NCT04122118
- Testing
- Medical Chart Review, Educational Intervention, Survey Administration
- Where
- United States
- Volunteers
- 26 people
- Sponsor
- Thomas Jefferson University
Preeclampsia
Use of Allied-health Professionals to Improve Treatment of Disease
The goal of this clinical trial is to learn if allied-health professionals can recruit and follow research participants, sustain engagement, and improve and diagnose treatment of diseases by facilitating transitions of care.
- Trial name
- NCT06337799
- Testing
- Research Pharmacist
- Volunteers
- 200 people
- Sponsor
- University of Iowa
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
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
Advanced HIV Disease
Advanced HIV Re-engagement in Care
Adults who are hospitalized in Lusaka, Zambia, and found to have advanced HIV disease will be enrolled and randomly assigned to receive the ARC intervention or standard of care.
- Trial name
- ARC (NCT07720128)
- Testing
- ARC
- Where
- Zambia
- Volunteers
- 724 people
- Sponsor
- University of Alabama at Birmingham
Fall, Accidental, Fall
Transport PLUS Intervention
Hypothesis: 'Transport PLUS,' a low cost, easily generalizable intervention performed by Emergency Medical Technicians while transporting a patient home from the hospital, can improve transitions of care and improve patient…
- Conditions
- Fall, Accidental, Fall, Hospital Readmission, Emergency Medical Services
- Trial name
- NCT03046771
- Testing
- Transport PLUS group
- Where
- United States
- Volunteers
- 58 people, healthy volunteers welcome
- Sponsor
- Icahn School of Medicine at Mount Sinai
HIV Infections, Adolescent Behavior
Improving Care and Community Representation for Adolescents and Young Adults Living With HIV in West Africa
Context: HIV-positive young people aged 15 to 24 are a heterogeneous population in terms of gender, age, mode of transmission, sexual orientation and risk-taking.
- Conditions
- HIV Infections, Adolescent Behavior, Transition
- Trial name
- TRANSITIONS (NCT05405322)
- Where
- 4 sites in Burkina Faso, Senegal
- Volunteers
- 267 people
- Sponsor
- Institut de Recherche pour le Developpement
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
End Stage Renal Disease, Kidney Failure
Virtual Ward for Home Dialysis
Home based renal replacement therapy (RRT), including peritoneal dialysis (PD) and home hemodialysis(HHD), offers enhanced quality of life and clinical advantages compared to conventional in-center hemodialysis.
- Conditions
- End Stage Renal Disease, Kidney Failure, Home Dialysis
- Trial name
- Virtual Ward (NCT01912001)
- Testing
- Telephone follow-up, Sympton Assessment
- Where
- 7 sites in Canada
- Volunteers
- 215 people
- Sponsor
- Christopher Chan
Heart Failure，Congestive, Mental Health (Depression)
Evaluation of Nurse-led Integrated Care of Complex Patients Facilitated By Telemonitoring: The SMaRT Study
In Canada, 3 out of 4 Canadians aged 65 and older have at least one chronic condition, while 1 in 4 seniors reported having three or more.
- Conditions
- Heart Failure，Congestive, Mental Health (Depression), Diabetes Mellitus, Chronic Obstructive Pulmonary Disease
- Trial name
- NCT05543720
- Testing
- Medly
- Where
- 4 sites in Canada
- Volunteers
- 350 people
- Sponsor
- University Health Network, Toronto