App to support post-hospital care for people with multiple chronic conditions
Care Transitions App for Patients With Multiple Chronic Conditions
This trial will test a smartphone/tablet app to help people aged 55+ with heart failure, diabetes, or chronic kidney disease manage their care after leaving the hospital.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 798 (estimated) |
| Ages | 55 Years and up |
| Sex | All |
| Sponsor | Brigham and Women's Hospital Academic / other |
| Locations | 1 site (Boston, Massachusetts) |
| Trial ID | NCT06051058 on ClinicalTrials.gov |
What this trial studies
This randomized controlled trial will test the Care Transitions App, a digital tool designed for older adults with multiple chronic conditions discharged from an academic general medicine service. The app combines four modules: falls-reduction content; a digital post-discharge care plan with education, medications, follow-up appointments, and warning signs; condition-specific post-discharge plans for diabetes, heart failure, and chronic kidney disease; and a post-discharge report for patient notes, questions, and recovery goals. Eligible patients will be randomized to receive the app or usual discharge procedures and followed for outcomes such as readmissions, post-discharge adverse events, medication adherence, and completion of follow-up care. The study seeks to see if the app improves communication across inpatient and ambulatory teams and reduces common post-discharge risks for people living with multiple chronic conditions.
Who should consider this trial
Good fit: English-speaking adults aged 55 or older with a Brigham PCP or appointment at participating Brigham locations who are hospitalized on a general medicine unit, discharged to home/home health/assisted living, and have heart failure, type 2 diabetes, or chronic kidney disease plus at least one other chronic condition are ideal candidates.
Not a fit: People admitted to specialty units (e.g., ICU, surgery, cardiology), non‑English speakers, pregnant or institutionalized individuals, those too ill or with severe cognitive impairment to use an app, or patients discharged too quickly are unlikely to benefit from participation.
Why it matters
Potential benefit: If successful, the app could reduce hospital readmissions and post-discharge adverse events (like falls and medication problems) while improving patients' ability to follow recovery plans.
How similar studies have performed: Previous transitional-care programs and some digital post-discharge tools have shown modest reductions in readmissions and improved follow-up in selected groups, but comprehensive app-based multi-condition interventions like this are still relatively novel.
Eligibility criteria
Show full inclusion / exclusion criteria
Inclusion Criteria: * Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit * Discharging to home, home health care service or assisted living * Fluent in spoken English in patient or healthcare proxy * Patients with at least one of the conditions listed below + one additional chronic condition on the problem list. * Patient with heart failure on the problem list * Patient with type 2 diabetes on the problem list * Patient with chronic kidney disease on the problem list Exclusion Criteria: * Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit * Pregnant * Prisoner, institutionalized individual or in police custody * Discharge planned within 3 hours of screening * Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia * Not fluent in spoken English in patient and health proxy * Unlikely to be discharged to home * Lacks a device capable of accessing the app * Lack of a working telephone for 30-day follow-up
Where this trial is running
Boston, Massachusetts
- Brigham and Women's Hospital — Boston, Massachusetts, United States (Recruiting)
Study contacts
- Principal investigator: Lipika Samal, MD, MPH — Brigham and Women's Hospital
- Study coordinator: Lipika Samal, MD, MPH
- Email: lsamal@bwh.harvard.edu
- Phone: 617-732-7063
How to participate
- Review the eligibility criteria above with your treating physician.
- Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
- Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.