Clinical trials: Transitions of Care, active
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
COPD Exacerbation, Care Transitions
Telehealth Education Leveraging Electronic Transitions Of Care for COPD Patients
Transitions of Care (TOC) between hospital, ambulatory, and home settings for high-risk, frequently hospitalized adults with chronic diseases, such as chronic obstructive pulmonary disease (COPD) are complex, costly, and…
- Trial name
- TELE-TOC (NCT05897125)
- Testing
- Virtual at Home Medication Reconciliation Visit(s), Virtual At Home Medication Education Visit(s), COPD advanced practice nurse Inpatient Consult
- Where
- United States
- Volunteers
- 218 people
- Sponsor
- University of Chicago
Type 2 Diabetes
Transitioning Recently Admitted Patients With Non-Insulin and Insulin-treated Type 2 Diabetes to Innovative Glucose Monitoring
The TRANSITION-CGM trial will evaluate whether starting continuous glucose monitoring (CGM) before hospital discharge improves blood glucose control in adults with type 2 diabetes compared with usual care using finger-stick blood…
- Trial name
- TRANSITION-CGM (NCT07890818)
- Testing
- Continuous glucose monitor
- Where
- United States
- Volunteers
- 218 people
- Sponsor
- University of Cincinnati
LTC-to-hospital Transfer Decision-making
Evaluation of the STEP Intervention for Long-Term Care Residents Facing Hospital Transfer Decisions
This trial will evaluate whether the Supporting Transitions and Empowering Preferences (STEP) toolkit can improve decision-making about hospital transfers in long-term care residents and their substitute decision-makers and…
- Trial name
- STEP (NCT07153341)
- Testing
- STEP Decision Support Toolkit
- Where
- 2 sites in Canada
- Volunteers
- 200 people
- Sponsor
- Bruyère Health Research Institute.
Peritoneal Dialysis (PD), Hemodialysis
Examine the Epidemiology and Outcomes of Transitions From PD-to-HD in Canada
Transitions from peritoneal dialysis to hemodialysis are common during kidney replacement therapy and may be associated with adverse outcomes.
- Conditions
- Peritoneal Dialysis (PD), Hemodialysis, Kidney Replacement Therapy
- Trial name
- UPLIFT-PD CORR (NCT07477210)
- Where
- Canada
- Volunteers
- 17,000 people
- Sponsor
- Ciusss de L'Est de l'Île de Montréal
Eating Disorders in Adolescence, Transition of Care
Feasibility of the TransitionED Framework for Youth and Young Adults With Eating Disorders
Moving from pediatric (children's) health care to adult health care can be challenging for youth and young adults with eating disorders.
- Trial name
- TransitionED 3 (NCT07518641)
- Testing
- TransitionED Healthcare Transition Framework
- Where
- 2 sites in Canada
- Volunteers
- 60 people
- Sponsor
- McMaster University
Sepsis, Sepsis and Septic Shock
Written Sepsis Education for Patients
This pilot feasibility randomized controlled trial (RCT) aims to determine if it feasible to recruit, deliver, and evaluate a written discharge educational material (a brochure) to adult Intensive Care Unit (ICU) patients…
- Conditions
- Sepsis, Sepsis and Septic Shock, Sepsis at Intensive Care Unit
- Trial name
- NCT07415096
- Testing
- Written Discharge Education, Usual Care
- Volunteers
- 30 people
- Sponsor
- McMaster University
Substance Use Disorders
Feasibility of an Interdisciplinary Intervention to Improve Care Transitions for Hospitalized Patients With Substance Use Disorders
The purpose of this study is to evaluate the feasibility and preliminary effectiveness of a primary care-based Interdisciplinary Addiction Care Transition (IntACT) team that will meet patients with substance use disorders (SUD)…
- Trial name
- IntACT (NCT07575373)
- Testing
- IntACT, Usual Care
- Where
- United States
- Volunteers
- 75 people
- Sponsor
- Michael Incze
Patient Navigation
Empowering Families of Migrant Children and Youth with Special Healthcare Needs
The goal of this randomized controlled trial is to test if a patient navigator program improves healthcare experiences and outcomes for migrant families caring for a child or youth with special healthcare needs (i.e.
- Trial name
- MiNav (NCT06373588)
- Testing
- Patient Navigator
- Where
- 3 sites in Canada
- Volunteers
- 324 people
- Sponsor
- McGill University Health Centre/Research Institute of the McGill University Health Centre
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
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
Lung Cancer
The Transitions Project: Efficacy Trial
The aim of this study is to evaluate the efficacy of a brief psychoeducational intervention to improve quality of life in patients with lung cancer who are transitioning from active treatment to surveillance.
- Trial name
- NCT05087251
- Testing
- Five Psycho-educational Session(s), One Psycho-educational Session(s)
- Where
- 2 sites in United States
- Volunteers
- 100 people
- Sponsor
- Massachusetts General Hospital
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
Prisoners, Substance Use History
Calls and Coordination for Transitions of Care at Re-entry
The goal of this clinical trial is to learn if a short program for people being released from prison can help connect them to medical care.
- Conditions
- Prisoners, Substance Use History, Chronic Medical Conditions, Psychiatric Condition
- Trial name
- Call2Care (NCT06794983)
- Testing
- In-person visit with study team member, In-person visit with NCM, Phone calls and texts
- Where
- United States
- Volunteers
- 488 people
- Sponsor
- University of Wisconsin, Madison
Caregiver Stress
iCare4Me Transitions
The goal of this randomized controlled trial is to examine the effect of a virtual face-to-face health coach intervention to improve self-care among caregivers of hospitalized older adults during care transitions compared to…
- Trial name
- iCare4Me T (NCT06167746)
- Testing
- Digital Health Information (DHI), Virtual Health Coach for You
- Where
- 3 sites in United States
- Volunteers
- 314 people
- Sponsor
- University of Pennsylvania
Stroke, Ischemic Stroke
Transitions of Care for Stroke Patients
For stroke patients, early initiation of therapy typically yields the best functional outcomes. Rehabilitation of stroke patients immediately after hospitalization minimizes deleterious effects of immobility and facilitates…
- Conditions
- Stroke, Ischemic Stroke, Intracerebral Hemorrhage
- Trial name
- NCT06011720
- Testing
- Improved transition of care.
- Where
- United States
- Volunteers
- 3,000 people
- Sponsor
- Deviyani Mehta, MD
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
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
Dementia, Caregiver
ED PLWD/Care Partner Text Messaging
The purpose of this research study is to develop and test a text-messaging intervention for emergency department (ED) discharge care transitions experienced by caregivers of older adults with cognitive impairment.
- Conditions
- Dementia, Caregiver, Emergency Department, Mobile Health Technology (mHealth)
- Trial name
- CAPTURE (NCT07423871)
- Testing
- CAPTURE Text Message Care Transition Support
- Where
- United States
- Volunteers
- 80 people
- Sponsor
- Yale University
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