Two hospital-to-home transition programs for older adults and their family caregivers

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 comparative study tests two approaches to post-hospital care for older adults: a patient-centered transition program and a family caregiver enhanced program. It will enroll 1,200 dyads (patients 65+ and their family caregivers) across 20 hospitals in five states, including rural and urban sites. The study will assess safety at home, readmission and ER visit rates, and the impact on patients’ daily activities, with family members actively involved in needs assessment, education, and skills-building. Eligible patients include those with mild cognitive impairment or dementia, English or Spanish speakers, and varying technology literacy. The caregiver program adds structured training and supports to improve post-discharge caregiving readiness.

Why it matters

Who can join: the full rules

Patient Inclusion Criteria:

* 65 and older
* English and Spanish speaking
* Preadmission location: community dwelling
* Distance from Hospital: Local and Distant (rural) included
* Cognitive impairment, dementia allowed
* Technology Literacy: Flexible from high to low
* EPIC readmission risk score over 12
* Discharged home

Patient Exclusion Criteria:

* Admitted from skilled nursing facility
* Discharged to skilled nursing facility
* Left Against Medical Advice (AMA)
* Planned readmission
* Died during index admission
* Caregiver unwilling to participate
* Admitted to surgical services

Caregiver Inclusion Criteria:

* Adults 18 and older
* English and Spanish speaking
* Providing tangible support to patient
* Distance from Hospital: Local and Distant (rural) included
* Only Mild Cognitive Impairment allowed
* Able to be trained in Video Visit Technology
* Available to support post-discharge

Caregiver Exclusion Criteria:

• Has a greater than a mild cognitive impairment (\< 12 on MoCA)

Where it's running

• Davie Medical Center
  Bermuda Run, North Carolina, United States Recruiting
• High Point Medical Center
  High Point, North Carolina, United States Recruiting
• Atrium Health Wake Forest Baptist Wilkes Medical Center
  North Wilkesboro, North Carolina, United States Recruiting
• Atrium Health Wake Forest Baptist Medical Center
  Winston-Salem, North Carolina, United States Recruiting

Study contacts

• Principal investigator: Thomas Houston, MD — Wake Forest University Health Sciences
• Study coordinator: Michiyah Kimber
• Email: michiyah.kimber@advocatehealth.org
• Phone: 336-716-5719

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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.