Improving care transitions and outcomes for heart failure patients receiving home health care
Official title: I-TRANSFER-HF: Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe: A Type 1 Hybrid Effectiveness Implementation Trial
Funded at Weill Medical Coll of Cornell Univ · NIH-11299300 · Data updated 2026-11-12
This study is looking to improve the care of heart failure patients after they leave the hospital by having nurses visit them at home soon after discharge and making sure they see a doctor within the first week, all to help them stay healthy and avoid going back to the hospital.
Quick facts
| Grant type | R01 grant |
|---|---|
| Study type | NIH-funded research |
| Funding institution | Weill Medical Coll of Cornell Univ NIH-funded |
| Lab location | 1 site (New York, United States) |
| Project start | September 10, 2023 |
| Project end | April 30, 2026 |
| Funding year | 2025 |
| Award (this year) | $118,650 |
| NIH project number | 3R01HL169312-02S1 |
| Project ID | NIH-11299300 on NIH RePORTER |
Who could benefit from this research
✓Could help
Ideal candidates for this research are adults aged 21 and older who have been hospitalized for heart failure and are transitioning to home health care.
✕Less likely to help
Patients who are not diagnosed with heart failure or those who do not require home health care services may not benefit from this research.
What this research studies
This research focuses on enhancing the care of heart failure patients who are discharged from the hospital and receive home health care. It aims to implement a protocol that includes early and intensive nurse visits within two days of discharge, along with an outpatient medical visit within the first week. By closely monitoring these patients at home, the study seeks to reduce hospital readmissions and improve overall health outcomes. The approach is based on previous findings that showed significant benefits from timely follow-up care.
Why it matters
Potential benefit: If successful, this research could significantly reduce hospital readmissions and improve the quality of life for heart failure patients.
How similar studies have gone: Previous studies have shown that early and intensive home health care can significantly reduce readmission rates for heart failure patients, indicating a promising approach.
Where this research is happening
-
Weill Medical Coll of Cornell Univ
New York, United States Active
Researchers
- Principal investigator: Sterling, Madeline R — Weill Medical Coll of Cornell Univ
- Study coordinator: Sterling, Madeline R
Related research
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Digital-first heart failure care delivery in Uganda
A targeted program in Uganda tests a digital care plan to help people with heart failure manage their symptoms at home.
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Digital-first heart failure care delivery in Uganda
A study to test digital self-care tools to help people with heart failure in Uganda manage symptoms and stay healthier.
About this research
- This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
- Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
- For full project details, budget, and progress reports, visit the official NIH RePORTER page.