RecruitingNot ApplicableNCT06051058

Care Transitions App for Patients With Multiple Chronic Conditions

Sponsor

Brigham and Women's Hospital

Enrollment

798 participants

Start Date

Oct 8, 2024

Study Type

INTERVENTIONAL

Conditions

Heart Failure Diabetes Mellitus Congestive Heart Failure Chronic Kidney Diseases Diabetes

Summary

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.

Eligibility

Min Age: 55 Years

Plain Language Summary

Simplified for easier understanding

This study tests a smartphone app designed to help older adults with multiple chronic conditions manage their transition from the hospital back to home. The app provides reminders, health tracking, and care guidance to reduce complications and hospital readmissions. **You may be eligible if...** - You are 55 or older and are being discharged from a general medicine hospital unit to home or home care - You have heart failure, type 2 diabetes, or chronic kidney disease — plus at least one other chronic condition - You speak English - You have a primary care provider at a participating clinic **You may NOT be eligible if...** - You are being discharged from an ICU, surgical, cardiology, oncology, or other specialty unit - You are pregnant, incarcerated, or institutionalized - You have cognitive difficulties that prevent you from using the app independently Talk to your doctor to see if this trial is right for you.

This summary was AI-generated to explain the trial in plain language. It is not medical advice. Always discuss eligibility with your doctor before enrolling in a clinical trial.

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Interventions

BEHAVIORALCare Transitions App

Patients in the intervention arm will be randomized to receive the Care Transitions App and utilize it to support their care transition care plan for multiple chronic conditions.