I-TRANSFER-HF for Heart Failure Patients in Home Health Care
This study, called I-TRANSFER-HF, is for adults with heart failure who are transitioning from the hospital to home health care. It aims to improve this transition and prevent readmissions. The study tests a new approach called I-TRANSFER-HF, which includes early and frequent home health nurse visits and an outpatient doctor's visit within 7 days of leaving the hospital. Researchers want to see if I-TRANSFER-HF can reduce the number of times people return to the hospital within 30 days compared to usual care. They also want to understand what makes this new approach easy or difficult to put into practice. You may be eligible if you are an adult hospitalized for heart failure and are discharged to a participating home health agency.
- Study design
- This study plans to enroll 1094 participants. It uses a stepped-wedge randomized design, meaning different groups will start the I-TRANSFER-HF intervention at different times.
- What's involved
- Not specified in the trial record.
- Compensation
- Not stated in the trial record.
- Follow-up
- Your hospital readmission status will be checked 30 days after your heart failure hospitalization.
AI-generated from the public study record. Only the study team can confirm whether you're eligible — confirm details with them before making decisions.
Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF)
At a glance
Conditions
NCT06118983
Where you'd take part
This study runs at 2 sites. They're the same protocol — you choose where, and that choice sets who your contact draft is addressed to.
VNS Health Partners in Care
New York, New Yorkstudy coordinator listed
Recruiting
Weill Cornell Medicine
New York, New Yorkstudy coordinator listed
Recruiting
Sites open and close at different times, so the status above is per site — it can differ from the study's overall status.
Study leadership
- Madeline R Sterling, MD, MPH, MS · PRINCIPAL_INVESTIGATOR · Weill Medical College of Cornell University
Who to contact
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Inclusion
Exclusion
What this trial measures
- All-cause 30-day hospital readmission30 days following post-Index HF Hospitalization
All-cause 30-day hospital readmission among adults hospitalized for heart failure who receive home health care after discharge and receive the I-TRANSFER-HF protocol compared to usual care, as assessed by Medicare claims
- Number of Eligible patients12 months
Number of heart failure patients eligible to receive I-TRANSFER-HF as assessed by Medicare claims data
- Number of Eligible Patients Who Received Protocol Components12 months
Number of heart failure patients who received both components of I-TRANSFER-HF (front-loaded home health nurse visits and early outpatient medical follow-up), one, or none as assessed by Medicare claims data
- Modality of outpatient follow-up12 months
The modality of outpatient follow-up received (in-person vs. virtual visit) as assessed by Medicare claims data
- Timeliness of Post-Hospital Discharge Home Health Nursing Evaluation12 months
The timeliness of first-week nursing visits within 2 days of hospital discharge as assessed by Medicare claims data
- Timeliness of Post-Hospital Outpatient Follow-Up12 months
The timeliness of outpatient visits within 7 days of hospital discharge as assessed by Medicare claims data
- Feasibility of implementing I-TRANSFER-HF (Qualitative Interviews)30 days after intervention (year of intervention)
Feasibility will be assessed through qualitative interviews with site stakeholders
- Feasibility of implementing I-TRANSFER-HF (Surveys)30 days after intervention (year of intervention)
Feasibility will be measured through the completion of the validated, 4-item, Feasibility of Intervention Measure (FIM). Items are measured on a 5-point Likert scale (Completely Disagree-Completely Agree). The score is calculated as the mean. The scale for this measure ranges from 4-20 with higher scores indicating greater perceived feasibility of the intervention.