Improving transitions and outcomes for heart failure patients receiving home health care
Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF): A Type 1 Hybrid Effectiveness- Implementation Trial
This study is testing a new program to help heart failure patients move from the hospital to home health care more smoothly and see if it can reduce the chances of them going back to the hospital within 30 days.
Quick facts
| Phase | Not applicable |
|---|---|
| Study type | Interventional |
| Enrollment | 1094 (estimated) |
| Ages | 18 Years and up |
| Sex | All |
| Sponsor | Weill Medical College of Cornell University Academic / other |
| Locations | 2 sites (New York, New York and 1 other locations) |
| Trial ID | NCT06118983 on ClinicalTrials.gov |
What this trial studies
This study aims to enhance the transition of heart failure patients from hospitals to home health care services through an intervention called I-TRANSFER-HF. The intervention includes early home health nurse visits and timely outpatient medical appointments to reduce hospital readmissions within 30 days. Researchers will compare outcomes before and after implementing I-TRANSFER-HF across various hospital-home health agency pairs, utilizing Medicare claims data and qualitative interviews to assess the intervention's effectiveness and real-world implementation challenges.
Who should consider this trial
Good fit: Ideal candidates for this study are adults hospitalized for heart failure who will transition to home health care services.
Not a fit: Patients who are discharged home without home health care or to other facilities like rehabilitation centers or hospice may not benefit from this study.
Why it matters
Potential benefit: If successful, this intervention could significantly reduce hospital readmissions and improve the overall quality of life for heart failure patients transitioning to home care.
How similar studies have performed: Other studies have shown promise in improving hospital-to-home transitions for heart failure patients, suggesting that this approach may be effective.
Eligibility criteria
Show full inclusion / exclusion criteria
Aim 1, Inclusion Criteria: * Adults hospitalized for HF who transition from participating hospitals to their partner HHC agency during the study period. Aim 1, Exclusion Criteria: * Patients hospitalized for HF and discharged: home without HHC, or to an inpatient rehabilitation facility, skilled nursing facility, or hospice; patients with end stage renal disease on dialysis and those with left ventricular devices. Aim 2, Inclusion Criteria: \- Healthcare professional involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads. Aim 2, Exclusion Criteria: \- Healthcare professional not involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads.
Where this trial is running
New York, New York and 1 other locations
- VNS Health Partners in Care — New York, New York, United States (Recruiting)
- Weill Cornell Medicine — New York, New York, United States (Recruiting)
Study contacts
- Principal investigator: Madeline R Sterling, MD, MPH, MS — Weill Medical College of Cornell University
- Study coordinator: Madeline R Sterling, MD, MPH, MS
- Email: mrs9012@med.cornell.edu
- Phone: 6469625029
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.