Care Transitions App for Patients With Multiple Chronic Conditions

This study is testing a Care Transitions App designed to help patients with multiple chronic conditions, such as heart failure, diabetes, and chronic kidney disease, as they leave the hospital. The app aims to improve communication and understanding of care plans after discharge. We want to see if using this app can reduce problems like falls or other adverse events that can happen in the first 30 days after leaving the hospital. You may be able to join if you are 55 or older, have a Brigham primary care doctor, are going home or to assisted living after discharge, and speak English. You also need to have at least two chronic conditions.

Study design: This is an interventional study planning to enroll 798 participants. Participants will be randomly assigned to either use the Care Transitions App or receive standard care.
What's involved: Patients in the intervention group will use the Care Transitions App to support their care transition plan. The study measures outcomes at 30 days.
Compensation: Not stated in the trial record.
Follow-up: Participants will be followed for 30 days after discharge to measure post-discharge adverse events.

AI-generated from the public study record. Only the study team can confirm whether you're eligible — confirm details with them before making decisions.

Care Transitions App for Patients With Multiple Chronic Conditions

Recruiting

NAAges 55+InterventionalSupportive care

Brigham and Women's Hospital

~798 participants

Updated 2026-07-09 on ClinicalTrials.gov

What's tested:Care Transitions App

At a glance

Recruiting sites

1 of 1 listed site is recruiting right now

RecruitingSuspended, closed, or not yet open

What they're measuring

To determine the effect of the Care Transitions App on post-discharge adverse events

Measured over 30 Days

Conditions

Heart Failure

Congestive Heart Failure

Diabetes

Diabetes Mellitus

Chronic Kidney Diseases

Where it's being run

1 sites across 1 states

Massachusetts1

Study leadership

Lipika Samal, MD, MPH · PRINCIPAL_INVESTIGATOR · Brigham and Women's Hospital

Who to contact

Lipika Samal, MD, MPH

[email protected]

617-732-7063

Email the study team

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Do you actually qualify for this trial?

Add a private profile and we'll compare every criterion below against your situation — and tell you which ones are met, uncertain, or excluding.

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Eligibility criteria

Inclusion

Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit

Discharging to home, home health care service or assisted living

Fluent in spoken English in patient or healthcare proxy

Patients with at least one of the conditions listed below + one additional chronic condition on the problem list.

Patient with heart failure on the problem list

Patient with type 2 diabetes on the problem list

Patient with chronic kidney disease on the problem list

Exclusion

Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit

Pregnant

Prisoner, institutionalized individual or in police custody

Discharge planned within 3 hours of screening

Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia

Not fluent in spoken English in patient and health proxy

Unlikely to be discharged to home

Lacks a device capable of accessing the app

Lack of a working telephone for 30-day follow-up

What this trial measures

To determine the effect of the Care Transitions App on post-discharge adverse events30 Days
Overall rate of post-discharge adverse events

Trialytics