NCT06051058Recruiting
Care Transitions App for Patients With Multiple Chronic Conditions
Source: ClinicalTrials.gov · Last updated 9 Jul 2026
Brief summary (registry, in English)
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.
- Status (registry)
- Recruiting
- Study type
- Interventional
- Enrollment
- 798 (estimated)
- First submitted
- 18 Sept 2023
- Start date
- 8 Oct 2024
- Primary completion date
- Jun 2027
- Lead sponsor
- Brigham and Women's Hospital
- Diseases
- Chronic kidney disease, Heart failure
- NCT number
- NCT06051058
What you commit to
- Study type: Interventional
- Planned participants: 798
- From 8 Oct 2024 to the primary completion date, Jun 2027
- 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.
Prior treatment
- Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit
Other illness
- Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia
Other
- Pregnant
- Prisoner, institutionalized individual or in police custody
- Discharge planned within 3 hours of screening
- 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
Who the study is looking for
- 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
Age in the registry: 55 years to - · Sex: All · Accepts 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 |
|---|---|---|---|
| Brigham and Women's Hospital Coordinator of this site? Confirm its status | Boston | United States | Recruiting |
This page is information, not medical advice. Discuss any trial with your doctor.