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Care Transitions App for Patients With Multiple Chronic Conditions

Brigham and Women's Hospital · with Agency for Healthcare Research and Quality (AHRQ) · NCT06051058

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Opens the official ClinicalTrials.gov record, with the study team’s contacts. Bored Studies doesn’t enroll anyone.

Key facts

Compensation
Not posted. Ask the study team before screening.
Who can join
Ages 55+ · All sexes
Healthy volunteers
Accepted
Study type
Interventional · Not applicable
Target enrollment
798
US sites recruiting
1
Study start
October 8, 2024
Record last updated
July 9, 2026

Status re-checked against ClinicalTrials.gov within the last 12 hours.

What the study is about

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.

Being studied: Care Transitions App

Conditions: Heart Failure; Congestive Heart Failure; Diabetes; Diabetes Mellitus; Chronic Kidney Diseases

Eligibility criteria

Copied from the official record. The study team makes the final decision at screening.

Show full criteria

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

Recruiting US locations

  • Brigham and Women's Hospital

    Boston, MA 02120

    Site contact: Lipika Samal · lsamal@bwh.harvard.edu

Study contacts (from the official record)

  • Lipika Samal, MD, MPH · 617-732-7063 · lsamal@bwh.harvard.edu
  • Patricia Dykes, PhD · 617-525-3003 · pdykes@bwh.harvard.edu
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Care Transitions App for Patients With Multiple Chronic Conditions (NCT06051058) | Bored Studies