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Care Transitions App for Patients With Multiple Chronic Conditions

Who can join

As published by the study on ClinicalTrials.gov. "Not stated" means the study hasn't said — ask the study team.

Age
55 Years and older
Sex
All sexes
Healthy volunteers
Accepted
Compensation
Not stated

Other requirements are listed under Eligibility below. Only the study team can confirm whether you can join.

What to expect

No one can promise a trial will help you personally — that is what the research is trying to find out.

What participation involves

Not stated in the study description — ask the study team about visits and procedures.

Compensation
Not stated
  • Study-related exams and procedures are typically provided at no cost. This is how many trials work in general — confirm the details for this study with the study team.
  • Participants are monitored closely by the research team throughout the study.
  • Some participants may receive access to an investigational treatment, which is still being studied.
  • Your participation helps researchers learn whether this approach could help future patients.

About this study

In plain language

This study tests the Care Transitions App for people age 55 and older with more than one long-term health condition. The app helps patients plan care after leaving the hospital, prevent falls, manage symptoms, and record questions and recovery goals.

The objective of this study is to widely implement and evaluate the Care Transitions App in a randomized controlled trial. The app the investigators designed for patients with multiple chronic conditions has four envisioned modules: 1) falls-reduction content, 2) a digital post-discharge transitional care plan (e.g., after hospital care plan, including education, medications, follow-up appointments, warning signs to watch for, nutrition, and other care plan activities), 3) a new module for patients with MCC (diabetes, congestive heart failure, and chronic kidney disease) including condition-specific post-discharge care plans with relevant symptom management activities, 4) a new post-discharge report module which summarizes key care transition findings and allows for patients to enter notes and questions for their providers and their own goals for recovery.

Compensation is read from the study's own description and may be missing — always confirm with the study team.

Eligibility

Who can join

  • Age 55 or older and leaving a Brigham and Women’s Hospital (BWH) general medicine unit.
  • Have a Brigham primary care provider or an appointment at one of the 15 study locations.
  • Going home, home with health care services, or to assisted living.
  • You or your health care proxy (someone who can make health decisions for you) speaks English fluently.
  • Your medical record lists heart failure (the heart does not pump well), type 2 diabetes (high blood sugar), or chronic kidney disease (long-term kidney damage), plus at least one other long-term condition.

Who can't join

  • Age 55 or older, have a primary care provider at Westwood, Pembroke, or Transition Clinic, and are admitted to intensive care or a specialty unit, such as surgery, heart care, cancer care, bone care, or pregnancy and women’s health care.
  • Pregnant.
  • In prison, living in an institution, or in police custody.
  • Expected to leave the hospital within 3 hours of the eligibility check.
  • Too ill to take part, or have active psychosis (loss of touch with reality), serious mental illness, delirium (sudden confusion), or severe dementia (major memory and thinking problems).
  • Neither you nor your health care proxy speaks English fluently.
  • Unlikely to go home after leaving the hospital.
  • Do not have a device that can use the app or a working phone for follow-up after 30 days.

Simplified for readability. The official criteria below are what the study team uses.

Official eligibility criteria

Inclusion Criteria: * Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit * Discharging to home, home health care service or assisted living * Fluent in spoken English in patient or healthcare proxy * Patients with at least one of the conditions listed below + one additional chronic condition on the problem list. * Patient with heart failure on the problem list * Patient with type 2 diabetes on the problem list * Patient with chronic kidney disease on the problem list Exclusion Criteria: * Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit * Pregnant * Prisoner, institutionalized individual or in police custody * Discharge planned within 3 hours of screening * Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia * Not fluent in spoken English in patient and health proxy * Unlikely to be discharged to home * Lacks a device capable of accessing the app * Lack of a working telephone for 30-day follow-up

Study sites (1)

MA