Improving transitions and outcomes for heart failure patients receiving home health care

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 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.

Why it matters

Who can join: the full rules

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 it's running

• 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

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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.