RightFit
RecruitingNot applicable

Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF)

Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF): A Type 1 Hybrid Effectiveness- Implementation Trial

Who can join

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

Age
18 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

  • Procedures mentioned: Interviews

Only what the study's summary and detailed description on ClinicalTrials.gov say. Time periods may describe the whole study or a part of it — ask the study team what applies to you.

Show the study's own words
  • "They will also interview people from these hospitals and agencies to see how I-TRANSFER-HF is being implemented under real-world conditions."
  • "H2 requires conducting qualitative interviews with key stakeholders across the 4 hospital-agency pairs to identify barriers and facilitators that influence I-TRANSFER-HF's implementation."
  • "The study will assess the intervention's acceptability, feasibility, fidelity, and adaptation with interviews and Medicare claims data using a multi-methods approach and guided by the updated Consolidated Framework for Implementation Research (CFIR 2.0)."
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 I-TRANSFER-HF, a care plan that combines early home nurse visits with medical visits after leaving the hospital. It is for adults with heart failure, a condition in which the heart does not pump blood well, who receive home health care. Researchers will see if the plan reduces hospital returns within 30 days and ask health care workers how easy or hard it is to use.

This study is trying to improve the hospital-to-home transition for people with heart failure who receive home care services. The study will test an intervention called I-TRANSFER-HF, which differs from usual care by combining early home health nurse visits and outpatient medical appointments. The study is interested in two questions: 1. Is I-TRANSFER-HF better than usual care at preventing heart failure patients from returning to the hospital within 30 days? 2. Are there parts of I-TRANSFER-HF that are easy or hard to implement in the real world? The researchers will answer these questions by testing the intervention among pairs of hospitals and home health agencies across the country. During the study, the hospital-agency pairs will be asked to implement I-TRANSFER-HF. The researchers will then compare the results from before and after I-TRANSFER-HF was adopted. They will also interview people from these hospitals and agencies to see how I-TRANSFER-HF is being implemented under real-world conditions.

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

Eligibility

Who can join

  • Patients: Adults hospitalized for heart failure who move from a participating hospital to its partner home health agency during the study.
  • Health care workers: Must help heart failure patients move from hospital to home health care and help put I-TRANSFER-HF into use at one of the four participating hospital-agency pairs.

Who can't join

  • Patients: Sent home without home health care after a hospital stay for heart failure.
  • Patients: Sent to a live-in rehab center, skilled nursing facility, or hospice care.
  • Patients: Have kidney failure and receive dialysis, a treatment that filters the blood.
  • Patients: Have a device that helps the left side of the heart pump blood.
  • Health care workers: Are not involved in moving heart failure patients from hospital to home health care and putting I-TRANSFER-HF into use at a participating hospital-agency pair.

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

Official eligibility 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.

Study sites (2)

NY