[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-studies-list:{\"conditionNormalized\":\"care-transitions\",\"overallStatus\":[\"RECRUITING\",\"AVAILABLE\",\"NOT_YET_RECRUITING\"],\"orderBy\":\"LastUpdateSubmitDate:desc\",\"size\":25,\"offset\":0}":3,"health-study-condition:care-transitions":32},{"pageToken":4,"total":5,"offset":6,"count":5,"results":7},null,2,0,[8,59],{"id":9,"slug":10,"hasResults":11,"nctId":12,"briefTitle":13,"officialTitle":14,"acronym":15,"eligibilityCriteria":16,"healthyVolunteers":11,"sex":17,"minAge":18,"maxAge":4,"enrollmentInfo":19,"targetDuration":4,"studyType":22,"phases":23,"briefSummary":25,"conditions":26,"keywords":33,"overallStatus":46,"whyStopped":4,"lastUpdateSubmitDate":47,"lastUpdatePostDateStruct":48,"startDateStruct":51,"completionDateStruct":53,"leadSponsor":55,"locationsCount":58},"100639920","comprehensive-enhanced-care-management-under-calaim-for-high-risk-medi-cal-members-100639920",false,"NCT07587073","Comprehensive Enhanced Care Management Under CalAIM for High-Risk Medi-Cal Members","A Pragmatic Cluster-Randomized Evaluation of Enhanced Care Management With Community Supports, Transitional Care, and Residential Care Coordination for High-Risk Medi-Cal Members Under CalAIM in California","COMPASS-CalAIM","Inclusion Criteria:\n\n* Adult Medi-Cal managed care member in California.\n* Identified as high-risk for poor outcomes based on plan stratification or qualifying CalAIM criteria.\n* Eligible for ECM and at least one of the following: Transitional Care Services, Community Supports related to post-acute recovery, housing\u002Fresidential stabilization, or nursing facility transition\u002Fdiversion.\n* Recent discharge or active transition from hospital, emergency department, skilled nursing facility, post-acute facility, recuperative care, assisted living, residential behavioral health setting, or other qualifying level-of-care transition.\n* Able to provide informed consent, or eligible for waiver\u002Falteration of consent if approved for cluster-level pragmatic implementation research.\n\nExclusion Criteria:\n\n* Enrollment in hospice or expected survival less than 6 months at the time of the index episode.\n* Long-term custodial institutional placement without an anticipated community transition plan.\n* Current incarceration or detention is preventing intervention delivery.\n* Previous enrollment in this study during the same observation window.\n* Any condition that, in the investigator's judgment, makes participation infeasible or data interpretation unreliable.","ALL","18 Years",{"count":20,"type":21},1200,"ESTIMATED","INTERVENTIONAL",[24],"NA","This pragmatic, cluster-randomized trial will evaluate whether a comprehensive CalAIM-aligned care model consisting of Enhanced Care Management, selected Community Supports, Transitional Care Services, and residential care coordination improves population health outcomes among high-risk Medi-Cal managed care members in California compared with usual CalAIM service delivery. The intervention is intended to improve continuity of care after discharge, reduce potentially avoidable utilization, increase successful linkage to outpatient and social supports, and improve community tenure and patient-reported outcomes.",[27,28,29,30,31,32],"Complex Care","Post-Acute Care Utilization","Housing Instability","Residential Care Transition","Population Health Management","Care Transitions",[34,35,36,37,38,39,40,41,42,43,44,45],"CalAIM","Enhanced Care Management","Community Supports","Transitional Care Services","Residential Care","Recuperative Care","Short-Term Post-Hospitalization Housing","Nursing Facility Transition","Medi-Cal","Population Health","Care Coordination","California","NOT_YET_RECRUITING","2026-05-08",{"date":49,"type":50},"2026-05-14","ACTUAL",{"date":52,"type":21},"2026-10-01",{"date":54,"type":21},"2028-12-31",{"name":56,"class":57},"StratiHealth","INDUSTRY",1,{"id":60,"slug":61,"hasResults":11,"nctId":62,"briefTitle":63,"officialTitle":64,"acronym":65,"eligibilityCriteria":66,"healthyVolunteers":67,"sex":17,"minAge":18,"maxAge":4,"enrollmentInfo":68,"targetDuration":4,"studyType":22,"phases":70,"briefSummary":71,"conditions":72,"keywords":4,"overallStatus":73,"whyStopped":4,"lastUpdateSubmitDate":74,"lastUpdatePostDateStruct":75,"startDateStruct":77,"completionDateStruct":79,"leadSponsor":80,"locationsCount":58},"100531723","improving-care-transitions-for-medicaid-insured-individuals-with-co-occurring-serious-mental-illness-100531723","NCT06203509","Improving Care Transitions for Medicaid Insured Individuals With Co-occurring Serious Mental Illness","An Equity-focused Intervention to Improve Care Transitions for Medicaid Insured Individuals With Co-occurring Chronic Medical Conditions and Serious Mental Illness","THRIVE-SMI","Inclusion Criteria:\n\n* Medicaid insured\n* Residing in the state of Pennsylvania\n* Experienced a hospitalization at study hospital\n* Agrees to home care at partner home care setting.\n\nExclusion Criteria:\n\n* Individuals under age 18",true,{"count":69,"type":21},267,[24],"This study aims to evaluate the THRIVE clinical pathway at HUP, focusing on supporting Medicaid-insured individuals, including those with serious mental illness, following hospitalization. The study will assess clinician\u002Fadministrator perspectives on the pathway's feasibility, appropriateness, and acceptability and analyze referral patterns and post-discharge outcomes.\n\nThe objectives are:\n\n1. To conduct a qualitative study evaluating the implementation of THRIVE, particularly its adaptation to include patients with serious mental illness.\n2. To examine referral patterns, 30-day readmission rates, and ED utilization for THRIVE participants, comparing them with those receiving standard care.\n\nParticipants will be referred to home care services during hospitalization and seen by a home care nurse within 48 hours post-discharge. A discharging physician or Advanced Practice Provider will oversee care for 30 days or until a primary care or specialist visit. The Care Coordination Team will hold weekly case conferences for 30 days post-discharge to address both health and mental health needs. The study will compare outcomes of Medicaid-insured patients, including those with serious mental illness, to those receiving usual care.",[32],"RECRUITING","2026-04-28",{"date":76,"type":50},"2026-05-05",{"date":78,"type":50},"2024-04-15",{"date":52,"type":21},{"name":81,"class":82},"University of Pennsylvania","OTHER"]