Transitions of Care Clinic (TOCC) for Heart Failure

This study is testing a program called the Transitions of Care Clinic (TOCC) to help patients with heart failure with preserved ejection fraction (HFpEF) as they go from the hospital back home. The TOCC program includes an introduction to the program before you leave the hospital, educational videos about heart failure, and a heart failure kit with information. The goal is to see if this program can lower the number of times people are readmitted to the hospital within 30 days after being discharged. You might be able to join if you are 18 to 90 years old, were hospitalized for HFpEF at Ocean University Medical Center, and are going home. The study is currently unclear on its recruitment status.

Study design
This is an interventional study planning to enroll 150 participants. It is not specified if participants are randomly assigned to groups.
What's involved
Participants will receive the TOCC intervention, which includes educational videos and a heart failure kit. They will also have follow-up phone calls.
Compensation
Not stated in the trial record.
Follow-up
Participants will be followed for 30 days after hospital discharge to track readmission rates.

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NCT06937827

Transitions of Care Clinic (TOCC)

Recruiting
NAAges 18–90InterventionalHealth services
Hackensack Meridian Health
~150 participants
Updated 2026-02-11 on ClinicalTrials.gov
What's tested:HF Kit and Follow-ups

At a glance

Recruiting sites
1 of 1 listed site is recruiting right now
RecruitingSuspended, closed, or not yet open
What they're measuring
All-cause 30-day hospital readmission rate for heart failure
Measured over 30 days post discharge
Heart Failure With Preserved Ejection Fraction
1 sites across 1 states
New Jersey1
  • Alexandria Berns, PharmD · PRINCIPAL_INVESTIGATOR · Hackensack Meridian Health

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Eligibility criteria

Inclusion

Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
Patient discharged home with or without homecare

Exclusion

Refuse to participate in TOCC phone calls
Discharged to a facility
Discharged with homecare services
Discharged on hospice services
Hemodialysis
Leave against medical advice (AMA)
Pregnant
Diagnosed with dementia
Without medical capacity or unable to provide own consent
  • All-cause 30-day hospital readmission rate for heart failure30 days post discharge

    This measures the percentage of patients initially hospitalized for HF who are readmitted to the hospital for any reason within 30 days of discharge. This is a standard metric for evaluating HF care and aligns directly with the objective of reducing readmissions.