[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-studies-list:{\"conditionNormalized\":\"care-transition\",\"overallStatus\":[\"RECRUITING\",\"AVAILABLE\",\"NOT_YET_RECRUITING\"],\"orderBy\":\"LastUpdateSubmitDate:desc\",\"size\":25,\"offset\":0}":3,"health-study-condition:care-transition":26},{"pageToken":4,"total":5,"offset":6,"count":5,"results":7},null,3,0,[8,46,84],{"id":9,"slug":10,"hasResults":11,"nctId":12,"briefTitle":13,"officialTitle":13,"acronym":4,"eligibilityCriteria":14,"healthyVolunteers":15,"sex":16,"minAge":17,"maxAge":4,"enrollmentInfo":18,"targetDuration":4,"studyType":21,"phases":22,"briefSummary":24,"conditions":25,"keywords":27,"overallStatus":33,"whyStopped":4,"lastUpdateSubmitDate":34,"lastUpdatePostDateStruct":35,"startDateStruct":38,"completionDateStruct":40,"leadSponsor":42,"locationsCount":45},"100641567","comparing-two-acute-care-transition-programs-for-older-adults-and-their-family-caregivers-100641567",false,"NCT07661355","Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers","Patient Inclusion Criteria:\n\n* 65 and older\n* English and Spanish speaking\n* Preadmission location: community dwelling\n* Distance from Hospital: Local and Distant (rural) included\n* Cognitive impairment, dementia allowed\n* Technology Literacy: Flexible from high to low\n* EPIC readmission risk score over 12\n* Discharged home\n\nPatient Exclusion Criteria:\n\n* Admitted from skilled nursing facility\n* Discharged to skilled nursing facility\n* Left Against Medical Advice (AMA)\n* Planned readmission\n* Died during index admission\n* Caregiver unwilling to participate\n\nCaregiver Inclusion Criteria:\n\n* Adults 18 and older\n* English and Spanish speaking\n* Providing tangible support to patient\n* Distance from Hospital: Local and Distant (rural) included\n* Only Mild Cognitive Impairment allowed\n* Able to be trained in Video Visit Technology\n* Available to support post-discharge\n\nCaregiver Exclusion Criteria:\n\n• Has a greater than a mild cognitive impairment (≤ 22 on MCA)",true,"ALL","18 Years",{"count":19,"type":20},2560,"ESTIMATED","INTERVENTIONAL",[23],"NA","This study investigates better ways to help people after they leave the hospital and how to involve their families in this process. The main goal is to see if adding family support to a patient-centered hospital-to-home intervention helps patients stay safely at home, spend fewer days back in the emergency room or going back into the hospital. The study team also wants to see if the family-centered approach helps improve the patient's ability to do everyday activities without feeling overwhelmed. Two approaches are being compared: one focuses just on the patient, and the other includes special strategies to better support families involved too. Family will be involved in assessing what the patient and family needs. The family-focused approach not only emphasizes the experience, health, and safety of the patient but also the experience of the family member caring for the older adult. The study also involves families in education and provides families skills-building experiences that can help with caregiving stress, problem-solving, and communicating with the healthcare team. The approach will help the family member prepare for their loved one's transition home and provide coaching with the goal of reducing the mental, physical and financial burden of providing care at home. To spread the intervention across many states, the study team will be using telephone calls, video calls, and other technologies as families prefer.",[26],"Care Transition",[28,29,30,31,32],"hospitalization","older adults","aging","care transition","mild cognitive impairment","NOT_YET_RECRUITING","2026-06-16",{"date":36,"type":37},"2026-06-22","ACTUAL",{"date":39,"type":20},"2026-07",{"date":41,"type":20},"2031-11",{"name":43,"class":44},"Wake Forest University Health Sciences","OTHER",4,{"id":47,"slug":48,"hasResults":11,"nctId":49,"briefTitle":50,"officialTitle":51,"acronym":52,"eligibilityCriteria":53,"healthyVolunteers":11,"sex":16,"minAge":17,"maxAge":4,"enrollmentInfo":54,"targetDuration":4,"studyType":21,"phases":56,"briefSummary":57,"conditions":58,"keywords":62,"overallStatus":33,"whyStopped":4,"lastUpdateSubmitDate":74,"lastUpdatePostDateStruct":75,"startDateStruct":77,"completionDateStruct":79,"leadSponsor":81,"locationsCount":83},"100639134","medbridge-guided-ncmchw-post-discharge-support-for-high-risk-t2d-patients-100639134","NCT07599852","MEDBRIDGE-Guided NCM\u002FCHW Post-Discharge Support for High-Risk T2D Patients","MEDBRIDGE: AI-Driven Risk Stratification and Care Transition Intervention to Improve Diabetes Medication Management","MEDBRIDGE","Inclusion Criteria:\n\n* Adults aged 18 years or older\n* Diagnosis of type 2 diabetes (HbA1c of 6.5% or higher or relevant ICD-10 codes including E11, E13, E14, R73, L97.509, K31.84)\n* Discharged from UAB Hospital or its emergency departments\n* Receiving primary care at Cooper Green Mercy Health Services or UAB Post Discharge Clinic\n* Identified as high risk by the MEDBRIDGE prediction tool based on elevated risk of HbA1c elevation, diabetes-related emergency department visits, or diabetes-related hospitalizations within 3 months post-discharge\n\nExclusion Criteria:\n\n* Under age 18\n* No indication of type 2 diabetes\n* Not affiliated with Cooper Green Mercy Health Services or UAB Post Discharge Clinic for primary care\n* Unable to provide informed consent\n* Currently enrolled in another post-discharge intervention study",{"count":55,"type":20},45,[23],"This study tests whether a support program led by a nurse case manager and community health worker can help patients with type 2 diabetes manage their medications after leaving the hospital. Many patients with diabetes take multiple medications, and changes to these medications during hospital stays can cause confusion and lead to missed doses or incorrect use. This is especially common in communities with limited access to healthcare.\n\nThe study uses a computer-based tool called MEDBRIDGE (MEDication BRIDGE) to identify patients who may be at higher risk for problems after discharge, such as worsening blood sugar control or return visits to the emergency department. Patients identified as high-risk will receive 3 months of support from a nurse case manager and community health worker team, who will help with medication questions, coordinate with their doctor, and provide follow-up check-ins.\n\nThe main goal is to find out whether this type of support program is practical to deliver and acceptable to patients. The study will also track changes in blood sugar levels and emergency department visits. Forty-five patients will be enrolled over 6 months at the University of Alabama at Birmingham and Cooper Green Mercy Health Services in Jefferson County, Alabama.",[59,60,26,61],"Type 2 Diabetes","Medication Adherence","Medication Discrepancy",[59,63,64,65,66,67,68,69,70,71,72,73],"Medication Management","Care Transitions","Post-Discharge","Nurse Case Manager","Community Health Worker","Risk Stratification","Artificial Intelligence","HbA1c","Social Determinants of Health","Deep South","Underserved Populations","2026-05-14",{"date":76,"type":37},"2026-05-20",{"date":78,"type":20},"2029-05-01",{"date":80,"type":20},"2031-04-30",{"name":82,"class":44},"University of Alabama at Birmingham",2,{"id":85,"slug":86,"hasResults":11,"nctId":87,"briefTitle":88,"officialTitle":89,"acronym":4,"eligibilityCriteria":90,"healthyVolunteers":11,"sex":16,"minAge":91,"maxAge":4,"enrollmentInfo":92,"targetDuration":4,"studyType":21,"phases":94,"briefSummary":95,"conditions":96,"keywords":99,"overallStatus":103,"whyStopped":4,"lastUpdateSubmitDate":104,"lastUpdatePostDateStruct":105,"startDateStruct":107,"completionDateStruct":109,"leadSponsor":111,"locationsCount":113},"100573880","optimizing-care-transition-process-for-older-colorectal-surgery-patients-100573880","NCT06752031","Optimizing Care Transition Process for Older Colorectal Surgery Patients","Optimization of Care and Recovery in Older Colorectal Surgery Patients: A Hybrid Effectiveness-Implementation Pilot Study Protocol","Inclusion Criteria:\n\n* Adult patients (\\>65 years old)\n* Scheduled to undergo an elective colorectal surgery procedure\n* Ability to provide informed consent\n\nExclusion Criteria:\n\n* Emergent, non-elective colorectal procedures\n* Non-English Speaking","65 Years",{"count":93,"type":20},30,[23],"The goal of this study to test if a care transition intervention designed for older colorectal surgery patients would improve outcomes after discharge. It will assess the feasibility of the intervention.",[97,26,98],"Colorectal Surgery","Older Adults (65 Years and Older)",[100,101,102],"Colorectal surgery","Care transition","Older adults","RECRUITING","2026-05-08",{"date":106,"type":37},"2026-05-13",{"date":108,"type":37},"2025-10-30",{"date":110,"type":20},"2027-12",{"name":112,"class":44},"Massachusetts General Hospital",1]