RecruitingNot ApplicableNCT06118983

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

Sponsor

Weill Medical College of Cornell University

Enrollment

1,094 participants

Start Date

Jul 1, 2026

Study Type

INTERVENTIONAL

Conditions

Heart Failure

Summary

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.

Eligibility

Min Age: 18 Years

Plain Language Summary

Simplified for easier understanding

This study is testing a new program called I-TRANSFER-HF, designed to improve the handoff when heart failure patients leave the hospital and transition to receiving care at home through a home health care agency. The goal is to reduce complications and readmissions during this vulnerable transition period. **You may be eligible if...** - You were hospitalized for heart failure and are being discharged to a home health care agency that is part of the study - OR you are a healthcare professional involved in transitioning heart failure patients from hospital to home health care at one of the four participating hospital-home health care partnerships **You may NOT be eligible if...** - You were discharged home without home health services, or to a rehabilitation facility, skilled nursing facility, or hospice - You have end-stage kidney disease requiring dialysis - You have a left ventricular assist device (a mechanical heart pump) - You are a healthcare professional not involved in the heart failure transition process at a participating site 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

OTHERI-TRANSFER-HF

I-TRANSFER-HF is comprised of early and intensive HHC nurse visits and an outpatient visit within 7 days of discharge. Using a Hybrid Type 1, stepped wedge randomized trial design, we will test the effectiveness and implementation of I-TRANSFER-HF in partnership with 4 geographically diverse dyads of hospitals and HHC agencies ("hospital-HHC agency" dyads) across the US.

Locations(2)

VNS Health Partners in Care

New York, New York, United States

Weill Cornell Medicine

New York, New York, United States

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NCT06118983

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