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

Inclusion Criteria7

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 Criteria9

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

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.