Recruiting

Care Transitions App

Sponsor:

Brigham and Women's Hospital

Code:

NCT06051058

Conditions

Heart Failure

Congestive Heart Failure

Diabetes

Diabetes Mellitus

Chronic Kidney Diseases

Eligibility Criteria

Sex: All

Age: 55+

Healthy Volunteers: Accepted

Interventions

Care Transitions App

Study Details

Brief 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.

Conditions

Heart Failure

Congestive Heart Failure

Diabetes

Diabetes Mellitus

Chronic Kidney Diseases

Study ID

NCT06051058

Start date

Oct 8, 2024

Status verified date

Jul, 2026

Completion date

Dec, 2027

Anticipated

Primary completion date

Jun, 2027

Anticipated

Eligibility Criteria

Eligibility Criteria

Sex: All

Age: 55+

Healthy Volunteers: Accepted

Inclusion Criteria:

  • 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 Criteria:

  • 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

Study Design

Enrollment

798 participants

Anticipated

Allocation

Randomized

Intervention Model

Parallel Assignment

Primary purpose

Supportive Care

Interventions and Outcome Measures

Arms

experimental: Experimental: Care Transitions App

Use of the Care Transitions App to support the care transition for patients hospitalized and discharged with multiple chronic conditions will be compared to usual care.

no intervention: No Intervention: Usual Care

Usual care transition care for patients hospitalized and discharged with multiple chronic conditions.

Interventions

Care 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.

Primary outcome measure

  • To determine the effect of the Care Transitions App on post-discharge adverse events [ Time Frame: 30 Days ]

Central Contacts and Locations

Central contacts

Lipika Samal, MD, MPH

617-732-7063lsamal@bwh.harvard.edu

Patricia Dykes, PhD

617-525-3003pdykes@bwh.harvard.edu

Locations

Brigham and Women's Hospital

Recruiting

Boston, Massachusetts, United States, 02120

Contacts

Lipika Samal

lsamal@bwh.harvard.edu

More Information

Sponsor

Brigham and Women's Hospital

Last update posted

Jul 9, 2026

Last verified

Jul, 2026

Trial information was received from ClinicalTrials.gov and was last updated on 2026-09-10. This information was provided to ClinicalTrials.gov by Brigham and Women's Hospital on 2026-07-09.