Clinical trials: Transitions of Care
Sleep, Participation
I-SLEPT: Integrated Sleep and Life Engagement Program for Transitions
Sleep is essential to functional recovery in inpatient medical settings; however, sleep is likely to be disrupted during rehabilitation and hospital admissions.
- Trial name
- I-SLEPT (NCT07317336)
- Testing
- I-SLEPT
- Where
- United States
- Volunteers
- 60 people
- Sponsor
- VA Office of Research and Development
Continuity of Patient Care
The Care Transitions Intervention
This intervention tests whether encouraging older patients and their caregivers to assert a more active role in their care transitions could improve clinical outcomes.
- Trial name
- NCT00244491
- Testing
- Care Transitions Intervention
- Where
- United States
- Volunteers
- 1,400 people
- Sponsor
- University of Colorado, Denver
Alzheimer Disease, Dementia
CONSTELLATIONS Living Lab: Improving the Care Transitions of Older Adults Living with Neurocognitive Disorders
The prevalence of major neurocognitive disorders (MNCDs), particularly Alzheimer's disease, among older adults is increasing. These individuals and their caregivers often face challenges due to inefficient and poorly coordinated…
- Conditions
- Alzheimer Disease, Dementia, Neurocognitive Decline
- Trial name
- NCT06608589
- Testing
- CoMPAS+ MNCDs Program - Quality improvement program targeting the care transitions of patients living with a major neurocognitive disorder and their caregivers
- Where
- Canada
- Volunteers
- 700 people
- Sponsor
- Laval University
Epilepsy, Uncontrolled Seizures
Epilepsy Emergency Department High Utilizer Program
We believe that there are many reasons that people with epilepsy get their health care through the emergency department (ED) instead of through primary care or neurology.
- Trial name
- NCT07663240
- Testing
- CHW-Led Transition-of-Care Intervention
- Where
- United States
- Volunteers
- 15 people
- Sponsor
- Morehouse School of Medicine
Patient Safety, Adverse Drug Event
Partnering With Patients for Improving Medication Safety During Transitions of Care: Implications for Work System Design
This project is to develop, implement, pilot evaluate, and disseminate a medication safety program (HomeTeam) that consolidates strategies to help patients by partnering with patients and their informal caregivers during…
- Trial name
- NCT03544034
- Testing
- HomeTeam Toolkit
- Where
- United States
- Volunteers
- healthy volunteers welcome
- Sponsor
- Johns Hopkins University
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
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
COPD, COPD Exacerbation
Nebulizer Versus Dry Powdered Inhalers for Chronic Obstructive Pulmonary Disease (COPD)
This will be a non-blinded feasibility (pilot) study comparing triple therapy nebulizer vs dry powdered inhalers (DPI) for care transitions in Chronic obstructive pulmonary disease (COPD) exacerbation patients.
- Trial name
- NCT03219866
- Testing
- Nebulizers, Dry Powder Inhaler, Brovana
- Where
- United States
- Volunteers
- 40 people
- Sponsor
- Wake Forest University Health Sciences
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
Stroke
Transitions of Care Stroke Disparity Study (TCSD-S)
The TCSD Study will identify disparities in transitions of stroke care and key factors associated with effective transitions of care through structured telephone interviews to evaluate medication adherence, healthy lifestyle…
- Trial name
- TCSD-S (NCT03452813)
- Where
- 2 sites in United States
- Volunteers
- 1,549 people
- Sponsor
- University of Miami
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
Cancer, Cancer Survivorship
AYA Cancer Transitions Program
This is a single-arm, minimal-risk, interventional behavioral clinical trial embedding structured transition support for adolescent and young adult (AYA) survivors of pediatric cancer transitioning into adult-focused survivorship…
- Conditions
- Cancer, Cancer Survivorship, Adolescent and Young Adult Cancer Survivors, Transitions of Care
- Trial name
- NCT07865013
- Testing
- Transitions Program
- Volunteers
- 100 people
- Sponsor
- University of Kansas Medical Center
Heart Failure
Mobile Integrated Health in Heart Failure
The purpose of this study is to compare how two different types of care after a hospitalization reduce hospital readmissions and symptom burden.
- Trial name
- NCT04662541
- Testing
- Mobile Integrated Health (MIH), Transitions of care coordinator (TOCC)
- Where
- 3 sites in United States
- Volunteers
- 2,005 people
- Sponsor
- Columbia University
Hospital Readmissions
Enhancing the Care Transitions Intervention With Peer Support to Reduce Disparities
Unplanned hospital readmissions are extremely costly to patients and our healthcare system. Being readmitted to the hospital also leads to increased risk of health complications for patients including infections and impairments…
- Trial name
- NCT04981977
- Testing
- Care Transitions Intervention, Care Transitions Intervention and Peer Support, Usual Care
- Where
- United States
- Volunteers
- 483 people, healthy volunteers welcome
- Sponsor
- University of South Florida
Care Transitions
Implementation and Evaluation of A Health Innovation to Support Medicaid-Insured Individuals Following Hospitalization
The goal of this stepped wedge pragmatic trial is to compare referral patterns and post discharge outcomes in Medicaid insured individuals discharge following a hospitalization].
- Trial name
- NCT05714605
- Testing
- THRIVE Intervention
- Where
- United States
- Volunteers
- 267 people
- Sponsor
- University of Pennsylvania
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