NCT04212962Active, not recruiting
Transitional Care Model Evaluation 2020
Evaluation of the Multisite Replication of the Transitional Care Model
Source: ClinicalTrials.gov · Last updated 8 Jul 2026
Brief summary (registry, in English)
The study is a randomized controlled trial to estimate the effects of the transitional care model (TCM) on hospital admissions and patients' experience during the year following the patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will be the coordinating center for the implementation. The study will be conducted in three large health systems spread throughout the U.S., drawing patients from seven hospitals in those systems. Eligible patients are older adults (age 65 and older) admitted to a participating hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia (PNA). The evaluation will be conducted by Mathematica.
- Status (registry)
- Active, not recruiting
- Study type
- Interventional
- Enrollment
- 962 (actual)
- First submitted
- 24 Dec 2019
- Start date
- Jul 2020
- Primary completion date
- Jul 2024
- Lead sponsor
- Mathematica Policy Research, Inc.
- Diseases
- Heart failure, COPD
- NCT number
- NCT04212962
What you commit to
- Study type: Interventional
- Participants enrolled: 962
- From Jul 2020 to the primary completion date, Jul 2024
- 1 site in 1 country
- Visits and tests: ask the trial team, the registry does not list them
Built from the registry fields of ClinicalTrials.gov. It describes the study, not your situation.
Who cannot take part
Copied verbatim from ClinicalTrials.gov and grouped by topic. Only the trial team decides who can take part.
Other illness
- Enrolled in Medicare's Hospice or End-Stage Renal Disease programs
- Presence of active and untreated psychiatric conditions (ICD10: F10-F29)
- Undergoing active cancer treatment
Other
- Long-term care resident
- Currently enrolled in another RCT
Who the study is looking for
- Age 65 years and older
- Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis
- English and non-English speaking, able to respond to questions
- Reachable by telephone after discharge
- Resides within the geographic service area
- Consent to participation
Age in the registry: 65 years to - · Sex: All · Does not accept healthy volunteers
Sites (1)
Sites in registry order. Pick your city on the disease page to sort them by distance.
| Site | City | Country | Site status |
|---|---|---|---|
| Mathematica Policy Research Coordinator of this site? Confirm its status | Princeton | United States | Unknown status |
This page is information, not medical advice. Discuss any trial with your doctor.