Improving early home nursing and follow-up care after heart-failure hospitalization
I-TRANSFER-HF: Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe: A Type 1 Hybrid Effectiveness Implementation Trial
This project uses early, intensive home nursing visits plus a clinic visit in the first week after hospital discharge to help adults with heart failure stay out of 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 ID | NIH-11129757 on NIH RePORTER |
What this research studies
If you have been hospitalized for heart failure and are going home with home health care, this program arranges a nurse visit within 2 days of discharge and aims for multiple nursing visits in the first week plus an outpatient clinic visit within that week. The team will compare outcomes for patients who receive this early, structured follow-up versus usual care while also testing ways to roll the approach out across home health agencies. The plan builds on earlier evidence showing lower 30-day readmission when both early home nursing and timely clinic follow-up occur, but only a small share of patients currently get that protocol. The study is led by Weill Cornell and will work with Medicare-certified home health agencies and clinics to implement the approach.
Who could benefit from this research
Good fit: Adults (typically Medicare-age or 21+) hospitalized for heart failure who are being discharged home with plans for Medicare-certified home health care are the ideal candidates.
Not a fit: People who do not have heart failure, who are discharged to skilled nursing facilities or long-term care rather than home, or who do not receive home health services are unlikely to be eligible or to benefit directly.
Why it matters
Potential benefit: If successful, this approach could reduce 30-day hospital readmissions and help people recover more safely at home after a heart-failure hospitalization.
How similar studies have performed: A prior large observational AHRQ-funded study linked the combination of early intensive home nursing visits and an outpatient visit to an 8% absolute (40% relative) reduction in 30-day readmissions, but randomized implementation trials are limited.
Where this research is happening
New York, United States
- 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
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 below.