New care pathways to support transition from hospital to home using AI and digital help
Official title: New Care Pathways for Supporting TRANSitional CARE From Hospital to Home Using AI and Personalized Digital Assistance
Run by Istituto Nazionale di Ricovero e Cura per Anziani · NCT07731126 · Data updated 2026-11-12
A digital remote monitoring system is tested to see if it can help older adults with multiple health issues avoid readmission within 30 days after leaving the hospital.
Quick facts
| Study type | Interventional |
|---|---|
| Ages | 65 Years and up |
| Sex | All |
| Enrollment | 210 (estimated) |
| Sponsor | Istituto Nazionale di Ricovero e Cura per Anziani Academic / other |
| Locations | 3 sites (Ancona and 2 other locations) |
| Status | Recruiting |
| Started | December 12, 2025 |
| Main results expected | February 28, 2027 |
| Study ends | February 28, 2027 |
| Registry record updated | July 28, 2026 |
| Trial ID | NCT07731126 on ClinicalTrials.gov |
Is this trial a fit for you?
✓Likely a good fit
Older adults over 65 with multimorbidity who can stand or walk with support, have MMSE ≥ 18, and a CFS score 2-7.
✕Probably not a fit
Individuals with severe dementia without a caregiver, terminal illness, or conditions precluding participation may not benefit.
A plain-English reading of the study's rules. Only the study team can confirm whether you qualify.
What this trial studies
The TRANSCARE study tests a digital remote monitoring ecosystem designed to support transitions from hospital to home in multimorbid seniors. It is a multicenter pilot conducted across Italy, Romania, and Norway, enrolling 210 participants aged 65 and older who are randomized to intervention or control groups. The study uses an AI-enabled digital platform to monitor patients remotely and identify risks that could lead to readmission, with tasks focused on self-management and early intervention. Eligible participants must be able to walk with or without support, have a MMSE of at least 18, and a Clinical Frailty Scale score between 2 and 7. Exclusion criteria include severe dementia without a caregiver, implanted cardiac devices, metastatic cancer, terminal illness, and other conditions that would prevent informed consent or participation.
Why it matters
Potential benefit: If successful, patients could experience fewer hospital readmissions and better support during the transition home.
How similar studies have gone: Previous studies in digital health and RPM have shown promise for reducing readmissions in high-risk older adults, though this specific transition-focused, multicenter approach is relatively novel.
Who can join: the full rules
Show full inclusion / exclusion criteria
Inclusion Criteria: * Able to stand and walk even with support; * Mini Mental State Examination (MMSE) ≥ 18; * Clinical Frailty Scale (CFS) score 2-7; Exclusion Criteria: * Allergy to nichel components; * Concomitant participation in other studies; * Severe dementia condition * Mild to moderate dementia condition in the absence of the caregiver * Terminal chronic renal failure with the need for dialysis * Inability or unwillingness to sign written informed consent; * Pacemaker or implantable cardioverter defibrillator; * Metastatic cancer or immunosuppressive therapy; * Significant visual or hearing impairment; * Severe systemic diseases with life expectancy \< 6 year; * Move to nursing home after discharge
Where it's running
-
IRCCS INRCA Hospital
Ancona, Italy Recruiting -
Farsund Kommune
Farsund, Norway Recruiting -
Institutul Inimii "Niculae Stăncioiu"
Cluj-Napoca, Romania Recruiting
Study contacts
- Principal investigator: Roberta Bevilacqua, Ph.D. — IRCCS INRCA, Ancona, Italy
- Study coordinator: Anna Rita Bonfigli, PhD
- Email: a.bonfigli@inrca.it
- Phone: 0718003719
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How to take part
- Review the eligibility criteria above with your treating physician.
- Check the official listing on ClinicalTrials.gov for the latest contact details and recruitment status.
- Contact the study coordinator or principal investigator to ask for pre-screening. Pre-screening is free and never obligates you to enroll.