N/A N=263 Home Based Care Transitions Tailored by Cognition and Patient Activation
Chronic Disease
Primary: Health Care Utilization — 7; 8; 4; 3 events
Clinical Trial Search
Completed trials with posted results — search by concept, filter by the parameters that matter at the bedside.
N/A N=1,679 Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions
Adverse Events · Readmissions · Patient Engagement
Primary: Proportion of Participants With an Adverse Event Within 30 Days After Index Discharge Date — 0.18; 0.23 proportion of participants — p=0.02
N/A N=31 CAPABLE Transitions: A Home Health-Based Intervention for the Hospital or Post-Acute Care Facility-to-Home Transition
Care Transitions · Dementia
Primary: Percentage of Participants Screened as Eligible — 180 Participants
N/A N=1,979 Paramedic Coached ED Care Transitions to Help Older Adults Maintain Their Health
Emergencies · Aging
Primary: Number of Participants Returning to the ED Within 30 Days of the Original ED Visit — 84; 69; 51; 113 Participants
N/A N=2,158 Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence
Care Transitions
Primary: Hospital Readmission — .956; .949; .698; .972 odds ratio
N/A N=140 A Technology Assisted Care Transition Intervention for Veterans With CHF or COPD
CHF · COPD
Primary: Pre-post Change in Combined Emergency and Urgent Care Service Utilization — 1.06; 1.03; 0.92; 0.71 care utilization events — p=0.45
N/A N=19 Transition From Hospital to Home Post Cardiac Condition
Cardiac Condition
Primary: See Primary Outcome Description Below — 8; 3; 8; 3 participants
N/A N=12 A Transition of Care Model From Hospital to Community for Hispanic/Latino Adult Patients With Diabetes.
Diabetes Mellitus
Primary: Emergency Department (ED) Visits Within 30 Days Post Discharge — 0 emergency department visits
N/A N=511 IVR-Enhanced Care Transition Support for Complex Patients
Congestive Heart Failure · Chronic Obstructive Pulmonary Disease
Primary: Re-hospitalizations — 27; 26; 8; 14 participants
Phase 3 N=835 Virtual Continuity and Its Impact on Complex Hospitalized Patients' Care
Automated Communication Tools · Complex Medical Patients
Primary: Medication Errors at Hospital Discharge — 645; 359 Errors
N/A N=78 iTransition Development
Human Immunodeficiency Virus · HIV Seropositivity
Primary: Linkage to Adult Care — 16; 22; 0; 0 Participants
N/A N=1,376 Coordinated Emergency Department Transitions
Alzheimer Disease or Associated Disorder
Primary: Percent of Eligible Emergency Department Visits With Completed Outreach — 547; 304 Emergency Department Visits
N/A N=465 Improving Transitional Care Experiences in Mental Health
Standard Treatment Versus Engagement Focused Treatment
Primary: Subjective Quality of Life — 3.9; 3.8; 4.3; 4.0 units on a scale
N/A N=324 Connect-Home Clinical Trial
Transitional Care · Caregivers · Patient Discharge
Primary: Care Transitions Measure-15 Score 7 Days After Skilled Nursing Facility Discharge — 75.80; 68.33 score on a scale — p=.62
N/A N=181 Social Work Intervention Focused on Transitions
Study Focus: 30-day Rehospitalizations Among At-risk Older Adults Randomized to a Social Work-driven Care Transitions Intervention · Heart Disease · Diabetes
Primary: 30-day Hospital Readmission — 11; 9 30-day hospital readmissions
N/A N=1,915 Improving Patient Prioritization During Hospital-homecare Transition
Diabetes Mellitus, Type 2 · Congestive Heart Failure · Obstructive Pulmonary Disease
Primary: Number of Rehospitalizations Within 60 Days After Hospital Discharge — 807 rehospitalizations
N/A N=127 Rural Options At Discharge Model of Active Planning
All Causes Hospital Admissions
Primary: Hospital Re-admissions Analyzed by Poisson Regression — 17; 4; 21; 5 Hospital Readmission — p=0.030
N/A N=31 Enhancing the Transition From Hospital to Home for Patients With Traumatic Brain Injury and Families
Brain Injuries, Traumatic · Transitional Care · Family Members
Primary: Change in Quality of Life as Measured by the Short Form-36 (SF-36) — 47.97 score on a scale
N/A N=1,029 PATient Navigator to rEduce Readmissions
Chronic Obstructive Pulmonary Disease · Heart Failure · Sickle Cell Disease
Primary: PROMIS Emotional Distress-Anxiety (v1.0, SF4a) — -0.2; -1.7 T-score
N/A N=631 Value of Technology to Transfer Discharge Information
Information Dissemination · Interprofessional Relations
Primary: Hospital Readmission, at Least One — 117; 119; 199; 196 participants
N/A N=38 Adapting Connect-Home Transitional Care for the Unique Needs of Persons With Alzheimer's Disease and Other Dementias and Their Caregivers
Pathologic Processes
Primary: Number of Patients for Whom the Intervention Components Were Feasible — 16; 19; 15; 16 Participants
N/A N=7,526 An Evaluation of Virtual Psychiatric Transition of Care Offered in Behavioral Health
Mental Health Issue
Primary: Number of Participants With All Cause Non-elective Acute Care Post Discharge Utilization Within 30 Days — 941; 973 Participants — p=<0.001
N/A N=210 Integrating Care After Exacerbation of COPD
Chronic Obstructive Pulmonary Disease
Primary: Number of Patients With Hospital Re-admission and Mortality — 84; 61 Participants
N/A N=156 Eliminating Risk of Preventable Adverse Drug Events at the Hospital-community Interface of Care
Adverse Drug Events
Primary: Health Services Utilization 3 Months Following Hospital Discharge — 3.33; 3.40 Health Services Utilizations — p=.87
N/A N=240 Improving Patient-Centered Care Delivery Among Patients With Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease
Primary: Mean Number of Chronic Obstructive Pulmonary Disease (COPD)-Related Hospitalizations and Emergency Department (ED) Visits Per Patient Within Each Study Arm — 0.72; 1.40…
N/A N=50 A Study of Acute Kidney Injury in Care Transitions
Acute Kidney Injury
Primary: Number of Subjects to Complete the ACT Program — 22 Participants
N/A N=192 Involving Nursing Home Residents and Their Families in Acute Care Transfer Decisions
Chronic Disease · Acute Disease
Primary: Preparation for Decision Making — 39.59; 36.00 score on a scale — p=0.046
N/A N=670 Improving Coordination and Transitions of Care in Stroke Patients
Stroke · Transient Ischemic Attack
Primary: Stroke Patient Education Retention Tool — 49; 52; 29; 38 Participants
N/A N=1,400 Integrated Care (IC) Models for Patient-Centered Outcomes
Diabetes · Asthma · Chronic Obstructive Pulmonary Disease
Primary: Patient Activation — 61.87; 63.73; 63.82; 63.15 score on a scale — p=0.0211
N/A N=1,500 Hospital to Home Outcomes
Focus: Hospitalized Patients
Primary: Number of Participants With Any Occurrence of Unplanned Re-hospitalization and/or Any Emergency/Urgent Care Visits Within 30 Days of Hospital Discharge — 133; 105…