App to support post-hospital care for people with multiple chronic conditions

Is this trial a fit for you?

A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.

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.

Why it matters

Who can join: the full rules

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 it's running

• 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

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How to take part

1. Review the eligibility criteria above with your treating physician.
2. Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
3. Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.