Improving care for older adults with chronic conditions

Evaluation of CMS Transitional Care and Chronic Care Management Services: Bridging the Gap and Maximizing Potential

['FUNDING_OTHER'] · HEBREW REHABILITATION CENTER FOR AGED · NIH-11170827

This study is looking at how helpful Transitional Care Management and Chronic Care Management services are for older adults, especially those with frailty and dementia, to see if these services can help them stay healthier, live longer, and spend more time at home instead of in the hospital.

Quick facts

Phase['FUNDING_OTHER']
Study typeNih_funding
SexAll
SponsorHEBREW REHABILITATION CENTER FOR AGED (nih funded)
Locations1 site (BOSTON, UNITED STATES)
Trial IDNIH-11170827 on ClinicalTrials.gov

What this research studies

This research evaluates the effectiveness of Transitional Care Management (TCM) and Chronic Care Management (CCM) services aimed at enhancing the health outcomes of older adults. It focuses on addressing the medical and psychosocial needs of patients, particularly those with frailty and dementia, by improving care coordination and increasing the adoption of these services. The study will analyze how these services can lead to more days spent at home, better survival rates, and reduced Medicare costs compared to usual care. A team of experts will utilize various methodologies to assess the impact of these services on older adults' health.

Who could benefit from this research

Good fit: Ideal candidates for this research are older adults, particularly those with frailty, dementia, and challenging social determinants of health.

Not a fit: Patients who are younger or do not have chronic conditions may not receive benefit from this research.

Why it matters

Potential benefit: If successful, this research could lead to improved health outcomes and quality of life for older adults with chronic conditions.

How similar studies have performed: Previous research has shown that similar patient-centered care approaches can lead to significant improvements in health outcomes for older adults.

Where this research is happening

BOSTON, UNITED STATES

Researchers

About this research

  1. This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
  2. Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
  3. For full project details, budget, and progress reports, visit the official NIH RePORTER page below.

View on NIH RePORTER →

Last reviewed 2026-05-15 by the Find a Trial editorial team. Information on this page is for educational purposes and is not medical advice. Always consult qualified healthcare professionals about clinical trial participation.