Improving care transitions and outcomes for heart failure patients receiving home health care

I-TRANSFER-HF: Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe: A Type 1 Hybrid Effectiveness Implementation Trial

NIH-funded research Weill Medical Coll of Cornell Univ · NIH-11299300

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 typeR01 grant
Study typeNIH-funded research
Funding institutionWeill Medical Coll of Cornell Univ NIH-funded
Lab location1 site (New York, United States)
Project IDNIH-11299300 on NIH RePORTER

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.

Who could benefit from this research

Good fit: 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.

Not a fit: Patients who are not diagnosed with heart failure or those who do not require home health care services may not benefit from this research.

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 performed: 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

New York, 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.
Last reviewed 2026-06-10 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.