App Supporting Patients With Several Long-Term Illnesses After Hospital Discharge
Tests a care transitions app for adults with heart failure, diabetes, or kidney disease.
Plain-language title generated from the registry record
Registry title: Care Transitions App for Patients With Multiple Chronic Conditions
Key facts
- Where
- Boston, United StatesSee the site
Where in United States
- Brigham and Women's HospitalBoston, United StatesTaking people
Questions to ask the study team
- How often do I need to come in, and for how long each time?
- Are travel costs paid?
- Can I keep my own doctor?
- What happens if I want to stop?
Trial details
- Who runs it
- Brigham and Women's Hospital
- Trial code
- NCT06051058
- Record updated
- 9 July 2026
- Original description
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.Read full original descriptionShow less
Care Transitions App for Patients With Multiple Chronic Conditions
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.
Inclusion: 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: Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit; Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia; 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.