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Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF)

Weill Medical College of Cornell University · with National Heart, Lung, and Blood Institute (NHLBI), Johns Hopkins University · NCT06118983

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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 18+ · All sexes
Healthy volunteers
Accepted
Study type
Interventional · Not applicable
Target enrollment
1094
US sites recruiting
2
Study start
July 28, 2026
Record last updated
August 21, 2026

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

What the study is about

This study is trying to improve the hospital-to-home transition for people with heart failure who receive home care services. The study will test an intervention called I-TRANSFER-HF, which differs from usual care by combining early home health nurse visits and outpatient medical appointments.

The study is interested in two questions

  • Is I-TRANSFER-HF better than usual care at preventing heart failure patients from returning to the hospital within 30 days?
  • Are there parts of I-TRANSFER-HF that are easy or hard to implement in the real world?

The researchers will answer these questions by testing the intervention among pairs of hospitals and home health agencies across the country. During the study, the hospital-agency pairs will be asked to implement I-TRANSFER-HF. The researchers will then compare the results from before and after I-TRANSFER-HF was adopted. They will also interview people from these hospitals and agencies to see how I-TRANSFER-HF is being implemented under real-world conditions.

Being studied: I-TRANSFER-HF

Conditions: Heart Failure

Eligibility criteria

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

Show full criteria

Aim 1, Inclusion Criteria:

  • Adults hospitalized for HF who transition from participating hospitals to their partner HHC agency during the study period.

Aim 1, Exclusion Criteria:

  • Patients hospitalized for HF and discharged: home without HHC, or to an inpatient rehabilitation facility, skilled nursing facility, or hospice; patients with end stage renal disease on dialysis and those with left ventricular devices.

Aim 2, Inclusion Criteria:

  • Healthcare professional involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads.

Aim 2, Exclusion Criteria:

  • Healthcare professional not involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads.

Recruiting US locations

  • VNS Health Partners in Care

    New York, NY 10017

    Site contact: Kathy Bowles, PhD, RN,FAAN · bowles@nursing.upenn.edu

  • Weill Cornell Medicine

    New York, NY 10021

    Site contact: Madeline R Sterling, MD, MPH, MS · 646-962-5029 · mrs9012@med.cornell.edu

Study contacts (from the official record)

  • Madeline R Sterling, MD, MPH, MS · 6469625029 · mrs9012@med.cornell.edu
All heart & blood pressure studies in New York →
Improving TRansitions ANd OutcomeS for Heart FailurE Patients in… (NCT06118983) | Bored Studies