Living With Multimorbidity: Care Coordination and Symptom Management Program (COORDINATE)
Enrolling by invitation · Not applicable
Conditions studied: Multimorbidity
In brief
The goal of this clinical trial is to learn if a new care program, called the COORDINATE Program, can help older adults with two or more chronic health conditions. These individuals are being discharged from special hospital units called Intermediate Care Units (IMCUs), which care for people who are very sick but don't need intensive care. The main questions this study wants to answer are: 1. Can the COORDINATE Program improve participants' quality of life? 2. Can the program reduce emergency visits, intensive care admissions, and rehospitalizations? Researchers will compare the COORDINATE Program to the enhanced usual care with extra support to see if it works better. Participants will receive either the COORDINATE Program or enhanced usual care. They will also complete surveys at three different time points: before starting the intervention, at 3 months, and at 12 months. For those in the COORDINATE Program group, a trained nurse will guide them through: 1. A needs assessment to find out what matters most to them 2. A list of helpful questions to ask their care team 3. Goal-setting to support managing their conditions 4. Tracking their symptoms and progress 5. Attend a discharge visit and have 5 follow-up phone or video calls over 3 months Participants in both groups will be compensated for completing the surveys. The study hopes to improve how care is given to older adults with complex health needs and reduce unnecessary hospital visits.
Key facts
- Study ID
- NCT07157982
- Run by
- Johns Hopkins University
- People needed
- 10
- Starts
- 2026-07-27
- Expected to finish
- 2028-03-01
- Last updated by the study team
- 2026-07-29
Who can join
Age: 50 and older. Sex: any. Healthy volunteers: not accepted.
You may qualify if…
- aged 50 years and older
- living with two or more chronic health conditions as identified by diagnosis in the electronic health record
- medically complex patients defined as those admitted to intermediate care units
- have a working telephone or contact method.
You may not qualify if…
- cannot provide informed consent
- non-English speakers
- incapacitated or have documented cognitive impairment
- are in hospice
Where it is running
- Johns Hopkins Health System — Baltimore, Maryland, United States
Full record on ClinicalTrials.gov
Trial information comes from ClinicalTrials.gov and is refreshed daily. TrialsForMe does not provide medical care and does not run the studies it lists.