[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-studies-list:{\"conditionNormalized\":\"transitional-care\",\"overallStatus\":[\"RECRUITING\",\"AVAILABLE\",\"NOT_YET_RECRUITING\"],\"orderBy\":\"LastUpdateSubmitDate:desc\",\"size\":25,\"offset\":0}":3,"health-study-condition:transitional-care":28},{"pageToken":4,"total":5,"offset":6,"count":5,"results":7},null,7,0,[8,49,79,105,137,164,192],{"id":9,"slug":10,"hasResults":11,"nctId":12,"briefTitle":13,"officialTitle":14,"acronym":15,"eligibilityCriteria":16,"healthyVolunteers":11,"sex":17,"minAge":4,"maxAge":4,"enrollmentInfo":18,"targetDuration":4,"studyType":21,"phases":22,"briefSummary":24,"conditions":25,"keywords":29,"overallStatus":36,"whyStopped":4,"lastUpdateSubmitDate":37,"lastUpdatePostDateStruct":38,"startDateStruct":41,"completionDateStruct":43,"leadSponsor":45,"locationsCount":48},"100640038","volunteer-facilitated-discharge-assistance-and-supports-at-home-dash-for-people-with-stroke-100640038",false,"NCT07590076","Volunteer Facilitated Discharge Assistance and Supports at Home (DASH) for People With Stroke","Volunteer Facilitated Discharge Assistance and Supports at Home (DASH) for People With Stroke: An Effectiveness-implementation Hybrid Trial.","DASH","Inclusion Criteria:\n\n* Confirmed diagnosis of stroke\n* Either undergoing or recently completed in-patient rehabilitation within the last 3 weeks\n* Lived at home pre-stroke\n* Discharged directly home (to own residence or that of a family member)\n* Live in one of the program implementation areas (i.e., Toronto, Ottawa)\n\nExclusion Criteria:\n\n* Discharged to additional hospital inpatient care, nursing home, or other long-term care\n* Inability to communicate in English\n* Inability to provide informed consent due to cognitive deficits","ALL",{"count":19,"type":20},840,"ESTIMATED","INTERVENTIONAL",[23],"NA","The goal of this clinical trial is to learn if a home visit by a trained volunteer can improve stroke recovery after a stroke survivor is discharged home from the hospital. The main questions it aims to answer are:\n\n1. After 3 months of being discharged from the hospital, does this additional volunteer support at home improve coping skills for stroke survivors?\n2. Does the effects of the volunteer support last over 3 to 6 months after being discharged home?\n\nResearchers will compare between a group who will receive the volunteer support and a group who will not to see if the additional support can improve stroke recovery.\n\nParticipants will:\n\n* Either receive volunteer support over an 8-week time period OR receive no additional volunteer support\n* Continue with their usual care plan and receive educational resources from the research team during the study\n* Complete online surveys during study enrollment, at 3 months, and at 6 months after hospital discharge",[26,27,28],"Stroke","Stroke Rehabilitation","Transitional Care",[30,31,32,33,34,35],"Patient Oriented Research","Community-Based Services","Intersectoral Partnership","Volunteers","Stroke rehabilitation","Transitional care","NOT_YET_RECRUITING","2026-05-15",{"date":39,"type":40},"2026-05-18","ACTUAL",{"date":42,"type":20},"2026-06",{"date":44,"type":20},"2028-04",{"name":46,"class":47},"Bruyère Health Research Institute.","OTHER",6,{"id":50,"slug":51,"hasResults":11,"nctId":52,"briefTitle":53,"officialTitle":54,"acronym":55,"eligibilityCriteria":56,"healthyVolunteers":11,"sex":17,"minAge":57,"maxAge":4,"enrollmentInfo":58,"targetDuration":4,"studyType":21,"phases":60,"briefSummary":61,"conditions":62,"keywords":65,"overallStatus":36,"whyStopped":4,"lastUpdateSubmitDate":69,"lastUpdatePostDateStruct":70,"startDateStruct":72,"completionDateStruct":74,"leadSponsor":76,"locationsCount":78},"100629700","mhealth-intervention-to-support-self-care-during-the-hospital-to-home-transition-in-individuals-with-heart-failure-100629700","NCT07478081","mHealth Intervention to Support Self-care During the Hospital to Home Transition in Individuals With Heart Failure","Evaluation of the Feasibility, Usability, and Preliminary Effects of an mHealth Intervention Complementary to Usual Care in Individuals With Heart Failure: Protocol for a Pilot Randomized Clinical Trial","HF-mHealth","Inclusion Criteria:\n\n* Age ≥ 18 years\n* Diagnosis of heart failure (NYHA Class II or III)\n* Clinically stable at discharge (no IV inotropes within 48 hours; hemodynamically stable)\n* Ownership of compatible smartphone (Android\u002FiOS)\n* Basic digital literacy\n* Availability of informal caregiver willing to support the process\n\nExclusion Criteria:\n\n* Life expectancy \\\u003C 6 months\n* Severe cognitive impairment (MMSE \\\u003C24 or documented dementia)\n* Inability to provide informed consent\n* Participation in another interventional study","18 Years",{"count":59,"type":20},30,[23],"This study is a pilot randomized controlled trial designed to evaluate the feasibility, acceptability, usability, and preliminary efficacy of a mobile health (mHealth) educational self-management intervention for individuals with heart failure during the transition from hospital to home. Participants will be randomly assigned in a 1:1 ratio to receive either usual care alone or usual care plus the mHealth intervention.\n\nThe mobile application is designed to support heart failure self-care through tailored educational content, symptom self-monitoring, automated feedback, behavioral reinforcement messages, caregiver involvement, and secure communication with the healthcare team. The application is educational in nature and does not replace standard medical treatment.\n\nA total of 30 participants will be enrolled and followed for 60 days after hospital discharge, with outcome assessments conducted at 30 and 60 days. Primary outcomes focus on feasibility, technology acceptance, and usability of the intervention. Secondary exploratory outcomes include changes in self-care behaviors, functional status, heart failure related hospital readmissions and natriuretic peptide levels. Results from this pilot study will inform the design of a future definitive randomized controlled trial.",[63,64,28],"Heart Failure","Self-care",[66,63,28,67,68,64],"mHealth","Patient Education","Self-Management","2026-03-17",{"date":71,"type":40},"2026-03-20",{"date":73,"type":20},"2026-03",{"date":75,"type":20},"2027-06",{"name":77,"class":47},"Universidad de la Sabana",1,{"id":80,"slug":81,"hasResults":11,"nctId":82,"briefTitle":83,"officialTitle":84,"acronym":85,"eligibilityCriteria":86,"healthyVolunteers":11,"sex":17,"minAge":57,"maxAge":4,"enrollmentInfo":87,"targetDuration":4,"studyType":21,"phases":89,"briefSummary":90,"conditions":91,"keywords":92,"overallStatus":96,"whyStopped":4,"lastUpdateSubmitDate":97,"lastUpdatePostDateStruct":98,"startDateStruct":100,"completionDateStruct":101,"leadSponsor":103,"locationsCount":78},"100616791","pharmacist-led-transition-of-care-program-in-the-emergency-department-pharm-toc-ed-a-pilot-trial-100616791","NCT07310199","Pharmacist-Led Transition of Care Program in the Emergency Department (Pharm TOC-ED): A Pilot Trial","Pharmacist-Led Transition of Care Program in the Emergency Department (Pharm TOC-ED): A Pilot Randomized, Parallel-Group, Open-Label Trial With Embedded Process Evaluation","PharmTOC-ED","Inclusion Criteria:\n\n* Adults (aged 18 years or more) discharged from the ED with at least one of the following:\n* Polypharmacy: Five or more scheduled prescription medications for chronic illnesses (i.e., chronic maintenance medications, even if such medications were not refilled during the index ED visit)\n* Discharged with a new prescription of high-risk medication, including:\n* Drugs with the potential of withdrawal symptoms upon abrupt discontinuation such as antipsychotics, antiepileptics, antidepressants, and tapering glucocorticoids.\n* Insulin (initiation or intensification of therapy)\n* Oral hypoglycemic agents\n* Visiting ED for an exacerbation of chronic illness (e.g., exacerbation of asthma, COPD, CHF, uncontrolled diabetes mellitus, hypertension urgency, uncontrolled epilepsy)\n\nExclusion Criteria:\n\n* The following patients will be excluded:\n* Presenting with acute minor illnesses\n* Lack of decision-making capacity (including documented moderate or severe dementia, altered mental status, unstable psychiatric illness, altered consciousness level, lack of orientation to person\u002Fplace\u002Ftime as reported in EHR, delirium, patients seen in the ED for a psychiatric evaluation)\n* Language barrier, i.e., inability to communicate in either English or Arabic as the intervention will be provided by English\u002FArabic speaking clinical pharmacists\n* Expected length of stay in Qatar of \\\u003C30 days post discharge (including transit passengers)\n* Substance use disorders (e.g., alcoholism, opioid dependency) or drug-seeking behavior, as reported in EHR\n* Prisoners who are serving an active sentence\n* Patients presenting for non-medical, socially driven reasons (e.g., seeking shelter, support, or resources) with no identifiable acute medical condition, and known to the ED team as recurrent visitors.\n* Discharge to a location other than home (e.g., patients transferred to another hospital, long-term or skilled nursing facility)\n* Study pharmacists unavailable to deliver the intervention if the patients were randomized to the intervention arm\n* Pregnant women\n* Patients seen for trauma or planned surgery\n* Terminally ill patients\n* Patients discharged from ED with watchful waiting (e.g., expected to be readmitted for an intervention such as surgical intervention if conservative management failed)\n* Patients who are admitted to the hospital after enrollment (i.e., following consent but prior to ED discharge)",{"count":88,"type":20},82,[23],"When patients leave the emergency department, mistakes with their medications are common and can lead to complications or hospital readmissions. Pharmacists are trained to help prevent these problems, but pharmacist-led transition of care services are not routinely provided in emergency departments.\n\nThis study is a small pilot randomized controlled trial designed to see whether a pharmacist-led transition of care program can be carried out successfully in the emergency department at Al-Wakra Hospital. The study will help determine if a larger trial is feasible in the future.\n\nPatients who are being discharged home from the emergency department and meet the study criteria will be invited to participate. Those who agree will be randomly assigned to one of two groups:\n\nUsual care, or Usual care plus the pharmacist-led transition of care program The pharmacist-led program includes reviewing the discharge prescription, checking and updating the medication list, providing medication education, arranging follow-up with a pharmacist-run clinic, communicating with outpatient pharmacists, and following up with the patient after discharge.\n\nThe pilot trial will help determine how many patients are eligible, how many agree to participate, how well the intervention can be delivered in the emergency department, and whether patients and staff find it acceptable. The results will be used to plan a larger study that will test whether this program can reduce healthcare use after discharge.",[28],[93,94,95],"transition of care","Pharmacy services","Emergency Department","RECRUITING","2026-01-19",{"date":99,"type":40},"2026-01-21",{"date":97,"type":40},{"date":102,"type":20},"2027-04-10",{"name":104,"class":47},"Dr. Muhammad Abdul Hadi",{"id":106,"slug":107,"hasResults":11,"nctId":108,"briefTitle":109,"officialTitle":110,"acronym":111,"eligibilityCriteria":112,"healthyVolunteers":11,"sex":17,"minAge":4,"maxAge":57,"enrollmentInfo":113,"targetDuration":4,"studyType":21,"phases":115,"briefSummary":116,"conditions":117,"keywords":122,"overallStatus":96,"whyStopped":4,"lastUpdateSubmitDate":127,"lastUpdatePostDateStruct":128,"startDateStruct":130,"completionDateStruct":132,"leadSponsor":134,"locationsCount":136},"100548990","hospital-to-home-transitional-care-interventions-h2h-tci-childrenyouth-with-special-health-care-needs-cyshcn-100548990","NCT06428175","Hospital-to-Home Transitional Care Interventions (H2H-TCI) Children\u002FYouth With Special Health Care Needs (CYSHCN)","Hospital-to-Home Care Coordination for Children and Youth With Special Health Care Needs","H2H-CYSHCN","Inclusion Criteria:\n\n* For this study, eligible children\u002Fyouth with special health care needs (CYSHCN) and adult parent\u002Fcaregiver dyads will be those who meet the following inclusion criteria:\n\n  1. Child is a CYSHCN, defined as having seen two or more distinct specialty areas for outpatient visits during the 12 months prior to index hospitalization admission date\n  2. Age of hospitalized child is under 18 years old\n  3. Child hospitalized on a general pediatrics inpatient service line at participating site\n  4. Adult parent\u002Fcaregiver for the child is 18 years or older\n\nExclusion Criteria:\n\n* Child exclusion criteria:\n\n  1. Child will be discharged to any location besides home (e.g., long-term care or residential facility, skilled nursing facility, inpatient acute rehabilitation, psychiatric facility)\n  2. Child is a ward of the state or has an ongoing social services investigation\n  3. Child is already receiving transitional care, intensive longitudinal care coordination (e.g., organ\u002Fdisease-specific clinical program, clinical division within the same institution as the hospital \\[e.g., Children's Complex Care Program at UNC; Complex Care Service at Duke\\]), and\u002For longitudinal population health care coordination as part of a bundled alternative payment care model.\n* Parent\u002Fcaregiver exclusion criteria include:\n\n  1. Age less than 18 years old\n  2. Diminished capacity to provide consent\u002Fparticipate\n  3. Primary language for parent\u002Fcaregiver is any language besides English or Spanish",{"count":114,"type":20},480,[23],"Aim 1: Compare the effectiveness of focused dose vs extended dose hospital-to-home Transitional Care Interventions (H2H-TCI) on health service use and parent-reported confidence for hospitalized CYSHCN. Aim 2: Compare the effectiveness of focused and extended dose H2H-TCI among vulnerable CYSHCN subgroups. Hypothesis: Both H2H-TCI arms will improve primary outcomes more for CYSHCN with higher versus lower clinical complexity; while extended H2H-TCI will better mitigate racial\u002Fethnic outcome disparities than focused H2H-TCI. Aim 3: Evaluate implementation context, processes, and mechanisms via a multi-phase mixed methods study design.",[118,119,28,120,121],"Health Care","Pediatrics","Comparative Effectiveness","Family Engagement",[123,124,125,126],"Special Needs","Hospital to Home Care","Children and Youth with Special Health Care Needs","Randomized Trial","2025-09-05",{"date":129,"type":40},"2025-09-11",{"date":131,"type":40},"2025-08-28",{"date":133,"type":20},"2029-02",{"name":135,"class":47},"Duke University",2,{"id":138,"slug":139,"hasResults":11,"nctId":140,"briefTitle":141,"officialTitle":142,"acronym":143,"eligibilityCriteria":144,"healthyVolunteers":11,"sex":17,"minAge":57,"maxAge":4,"enrollmentInfo":145,"targetDuration":4,"studyType":21,"phases":147,"briefSummary":148,"conditions":149,"keywords":150,"overallStatus":36,"whyStopped":4,"lastUpdateSubmitDate":155,"lastUpdatePostDateStruct":156,"startDateStruct":158,"completionDateStruct":160,"leadSponsor":162,"locationsCount":78},"100599088","traj--transition-in-rheumatology-from-adolescence-to-adulthood-100599088","NCT07079943","TRAJ : Transition in Rheumatology, From Adolescence to Adulthood","From Adolescence to Adulthood : Analysis of the Impact of the CAPADJA Transition Support Program in Rheumatology at Bordeaux University Hospital","TRAJ","Inclusion Criteria:\n\n* Patients who benefited from a pediatric-to-adult rheumatology transition consultation at Bordeaux University Hospital between 2017 and 2024\n* Patients over 18 years old at the time of completing the self-administered questionnaire.\n\nExclusion Criteria:\n\n* Patients who do not speak French\n* Patients who have refused to participating",{"count":146,"type":20},100,[23],"This study evaluates the impact of the CAPAdJA transition support program on care continuity for young patients with chronic rheumatic diseases at Bordeaux University Hospital. The primary objective is to compare the proportion of patients lost to follow-up six months after the transition consultation between those who benefited from CAPAdJA and those who did not.",[28],[35,151,152,153,154],"Lost to follow up","Patient-reported experience","Quality of life","Patient satisfaction","2025-07-22",{"date":157,"type":40},"2025-07-23",{"date":159,"type":20},"2025-07",{"date":161,"type":20},"2025-10",{"name":163,"class":47},"University Hospital, Bordeaux",{"id":165,"slug":166,"hasResults":11,"nctId":167,"briefTitle":168,"officialTitle":169,"acronym":4,"eligibilityCriteria":170,"healthyVolunteers":11,"sex":17,"minAge":57,"maxAge":4,"enrollmentInfo":171,"targetDuration":4,"studyType":21,"phases":173,"briefSummary":174,"conditions":175,"keywords":178,"overallStatus":96,"whyStopped":4,"lastUpdateSubmitDate":183,"lastUpdatePostDateStruct":184,"startDateStruct":186,"completionDateStruct":188,"leadSponsor":190,"locationsCount":78},"100534710","transitional-care-program-in-stroke-patients-with-hemiplegia-100534710","NCT06242366","Transitional Care Program in Stroke Patients With Hemiplegia.","Effects of Transitional Care Program in Stroke Patients on Self-care Behavior, Quality of Life, and Hospital Readmission: A Randomized Controlled Trial.","Inclusion Criteria:\n\n* Age from 18 years old.\n* The first diagnosis is acute ischemic stroke.\n* Hemiplegia\n* NIHSS 5-14 point (moderate impairment)\n* Telephone and Line Application used.\n* Can read and communicate in Thai language\n* Accept participants to research and inform consent.\n\nExclusion Criteria:\n\n* Aphasia\n* The Six Item Cognitive Impairment Test: 6CIT from 8 points in age from 60 years old.\n* Participants with illness severity or dead during the study.\n* Reject the study",{"count":172,"type":20},60,[23],"This study examines the effects of a transitional care program in stroke patients on self-care behavior, quality of life, and hospital readmission.\n\nThe research conceptual framework is based on the Transitional Care Model by Naylor. Sixty participants with stroke patients at Charoenkrung Pracharak Hospital will be recruited. These participants are stratified by block randomization using NIHSS score and divided into 2 groups; a control group (n=30) and an intervention group (n=30).\n\nThe program consisted of 2 phases: 1) Phase I during hospital admission and 2) Phase II following hospital discharge",[176,28,177],"Ischemic Stroke","Hemiplegia",[179,180,181,35,182],"Quality Of Life","Self-care behavior","Hospital Readmission","Stroke patients","2024-11-19",{"date":185,"type":40},"2024-11-21",{"date":187,"type":40},"2024-02-07",{"date":189,"type":20},"2025-08-01",{"name":191,"class":47},"Mahidol University",{"id":193,"slug":194,"hasResults":11,"nctId":195,"briefTitle":196,"officialTitle":197,"acronym":198,"eligibilityCriteria":199,"healthyVolunteers":11,"sex":17,"minAge":200,"maxAge":4,"enrollmentInfo":201,"targetDuration":4,"studyType":21,"phases":203,"briefSummary":204,"conditions":205,"keywords":208,"overallStatus":96,"whyStopped":4,"lastUpdateSubmitDate":210,"lastUpdatePostDateStruct":211,"startDateStruct":213,"completionDateStruct":215,"leadSponsor":217,"locationsCount":78},"100530707","advantage-implementation-and-evaluation-of-an-interprofessional-tranistional-care-model-for-frail-older-adults-100530707","NCT06190288","AdvantAGE: Implementation and Evaluation of an Interprofessional Tranistional Care Model for Frail Older Adults","AdvantAGE: Implementation and Evaluation of an Interprofessional Transitional Care Model for Frail Older Adults at the University Department of Geriatric Medicine FELIX PLATTER","AdvantAGE","Inclusion Criteria:\n\n* Currently admitted to the acute or rehabilitation ward of University Department of Geriatric Medicine\n* Reside in Basel-Stadt\n* Possess the ability to speak and comprehend the German language\n* Scheduled to be discharged to their home\n* 65 years or older\n* Identified by a clinician as having a high risk of deterioration due to frailty\n\nAdditionally, participants must meet at least one of the following criteria:\n\n* diagnosed with a complex chronic disease requiring support in self-management and disease management, or\n* facing socially challenging situations such as living alone without a supportive network or lacking a GP, or\n* admitted for an acute illness with a brief hospital stay (e.g., infection, cardiac decompensation) and need support in self- and disease management, and continuity of the therapy plan, including close monitoring.\n\nExclusion Criteria:\n\n* residing in a nursing home or being newly admitted to one\n* lacking informal caregivers and exhibiting severe cognitive impairment (MMS ≤23)\n* scoring \\\u003C50 on the motoric domain of the Functional Independence Measure (FIM)\n* having a psychiatric disorder that significantly impacts their ability to manage daily life at time of the discharge","65 Years",{"count":202,"type":20},250,[23],"This clinical trial at the University Department of Geriatric Medicine FELIX Platter in Basel, Switzerland, is designed to evaluate a new transitional care model aimed at helping frail older adults after they get discharged from the hospital. The AdvantAGE study aims to explore the following questions:\n\n* Does the new care model help reduce the number of patients who need to return to the hospital within 90 days?\n* How effective is the implementation of this care model?\n\nParticipants in the trial will be followed by advanced practice nurses for up to 90 days after hospital discharge. The patients and their caregivers will receive support in coordinating care, managing medications, and learning to manage the patient's health conditions on their own. Additionally, they will have the opportunity to engage in discussions about advanced care planning.",[28,206,207],"Multimorbidity","Geriatric Care",[209],"Transitional Care, Frailty, Rehospitalisation, Geratric Care","2024-02-01",{"date":212,"type":40},"2024-02-02",{"date":214,"type":40},"2024-01-08",{"date":216,"type":20},"2026-06-30",{"name":218,"class":47},"Thekla Brunkert"]