Care Transitions App for Patients With Multiple Chronic Conditions

Recruiting now · Not applicable

Conditions studied: Heart Failure, Congestive Heart Failure, Diabetes, Diabetes Mellitus, Chronic Kidney Diseases

In brief

The objective of this study is to widely implement and evaluate the Care Transitions App in a randomized controlled trial. The app the investigators designed for patients with multiple chronic conditions has four envisioned modules: 1) falls-reduction content, 2) a digital post-discharge transitional care plan (e.g., after hospital care plan, including education, medications, follow-up appointments, warning signs to watch for, nutrition, and other care plan activities), 3) a new module for patients with MCC (diabetes, congestive heart failure, and chronic kidney disease) including condition-specific post-discharge care plans with relevant symptom management activities, 4) a new post-discharge report module which summarizes key care transition findings and allows for patients to enter notes and questions for their providers and their own goals for recovery.

Key facts

Study ID

NCT06051058

Run by

Brigham and Women's Hospital

People needed

798

Starts

2024-10-08

Expected to finish

2027-12-01

Last updated by the study team

2026-07-09

Who can join

Age: 55 and older. Sex: any. Healthy volunteers: accepted.

You may qualify if…

• Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit
• Discharging to home, home health care service or assisted living
• Fluent in spoken English in patient or healthcare proxy
• Patients with at least one of the conditions listed below + one additional chronic condition on the problem list.
• Patient with heart failure on the problem list
• Patient with type 2 diabetes on the problem list
• Patient with chronic kidney disease on the problem list

You may not qualify if…

• Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit
• Pregnant
• Prisoner, institutionalized individual or in police custody
• Discharge planned within 3 hours of screening
• Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia
• Not fluent in spoken English in patient and health proxy
• Unlikely to be discharged to home
• Lacks a device capable of accessing the app
• Lack of a working telephone for 30-day follow-up

Where it is running

• Brigham and Women's Hospital — Boston, Massachusetts, United States (enrolling)

Full record on ClinicalTrials.gov

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