Care transition intervention for patients with advanced cancer after hospital discharge

Randomized Trial of a Care Transition Intervention for Hospitalized Patients with Advanced Cancer

Not applicable Interventional Massachusetts General Hospital · NCT05142345

This study is testing a new video visit program with an oncology nurse for patients with advanced cancer after they leave the hospital to see if it helps them feel more confident and satisfied with their care while reducing the chances of going back to the hospital.

Quick facts

PhaseNot applicable
Study typeInterventional
Enrollment286 (estimated)
Ages18 Years and up
SexAll
SponsorMassachusetts General Hospital Academic / other
Locations1 site (Boston, Massachusetts)
Trial IDNCT05142345 on ClinicalTrials.gov

What this trial studies

This study examines the CONTINUUM intervention, which involves a supportive care-focused video visit with an oncology nurse practitioner within three business days of hospital discharge for patients with advanced cancer. The goal is to improve post-discharge transitions of care by reconciling medications, managing symptoms, reviewing care plans, and scheduling follow-up appointments. The study will compare the effectiveness of this intervention against standard care in enhancing patient confidence, satisfaction with communication, and reducing hospital readmissions within 30 days.

Who should consider this trial

Good fit: Ideal candidates are adults aged 18 and older with a recent unplanned admission for advanced cancer at Massachusetts General Hospital.

Not a fit: Patients who were admitted electively or discharged to locations other than home, or those who expired during admission, will not benefit from this study.

Why it matters

Potential benefit: If successful, this intervention could significantly improve the management of health conditions and reduce hospital readmissions for patients with advanced cancer.

How similar studies have performed: Previous pilot trials have shown that similar interventions can be feasible and acceptable, indicating potential for success in this randomized controlled trial.

Eligibility criteria

Show full inclusion / exclusion criteria
Inclusion Criteria:

* Age \>= 18 years
* First unplanned admission to the oncology service at Massachusetts General Hospital (MGH) since diagnosis of advanced cancer
* Known diagnosis of advanced breast, thoracic, genitourinary, or gastrointestinal cancer
* Receiving ongoing oncology care at MGH
* Verbal fluency in English
* Internet/wifi or telephone access
* Residing in Massachusetts at the time of hospital discharge

Exclusion Criteria:

* Admitted electively
* Discharged to a location other than home or expired during admission
* Discharged with hospice services

Where this trial is running

Boston, Massachusetts

Study contacts

How to participate

  1. Review the eligibility criteria above with your treating physician.
  2. Visit the official trial page on ClinicalTrials.gov for the most current contact information and recruitment status.
  3. Contact the listed study coordinator or principal investigator to request pre-screening. Pre-screening is free and never obligates you to enroll.
Conditions CancerFollow-Up CareConsultation, RemoteAdvanced CancerCare Services, HomeHospitalizationCare Transition Intervention
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.