[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-study-detail:100520015":3},{"organization":4,"armGroups":7,"interventions":19,"overallOfficials":25,"centralContacts":29,"locations":38,"responsibleParty":54,"collaborators":56,"id":60,"slug":18,"hasResults":61,"nctId":62,"briefTitle":63,"officialTitle":63,"acronym":18,"eligibilityCriteria":64,"healthyVolunteers":65,"sex":66,"minAge":67,"maxAge":18,"enrollmentInfo":68,"targetDuration":18,"studyType":71,"phases":72,"briefSummary":74,"conditions":75,"keywords":18,"overallStatus":40,"whyStopped":18,"lastUpdateSubmitDate":81,"lastUpdatePostDateStruct":82,"startDateStruct":85,"completionDateStruct":87,"leadSponsor":89,"locationsCount":90},{"fullName":5,"class":6},"Brigham and Women's Hospital","OTHER",[8,14],{"label":9,"type":10,"description":11,"interventionNames":12},"Experimental: Care Transitions App","EXPERIMENTAL","Use of the Care Transitions App to support the care transition for patients hospitalized and discharged with multiple chronic conditions will be compared to usual care.",[13],"Behavioral: Care Transitions App",{"label":15,"type":16,"description":17,"interventionNames":18},"No Intervention: Usual Care","NO_INTERVENTION","Usual care transition care for patients hospitalized and discharged with multiple chronic conditions.",null,[20],{"type":21,"name":22,"description":23,"armGroupLabels":24,"otherNames":18},"BEHAVIORAL","Care Transitions App","Patients in the intervention arm will be randomized to receive the Care Transitions App and utilize it to support their care transition care plan for multiple chronic conditions.",[9],[26],{"name":27,"affiliation":5,"role":28},"Lipika Samal, MD, MPH","PRINCIPAL_INVESTIGATOR",[30,34],{"name":27,"role":31,"phone":32,"phoneExt":18,"email":33},"CONTACT","617-732-7063","lsamal@bwh.harvard.edu",{"name":35,"role":31,"phone":36,"phoneExt":18,"email":37},"Patricia Dykes, PhD","617-525-3003","pdykes@bwh.harvard.edu",[39],{"facility":5,"status":40,"city":41,"state":42,"zip":43,"country":44,"cosmosGeoPoint":45,"geoPoint":50,"contacts":51},"RECRUITING","Boston","Massachusetts","02120","United States",{"type":46,"coordinates":47},"Point",[48,49],-71.05977,42.35843,{"lat":49,"lon":48},[52],{"name":53,"role":31,"phone":18,"phoneExt":18,"email":33},"Lipika Samal",{"type":28,"investigatorFullName":53,"investigatorTitle":55,"investigatorAffiliation":5,"oldNameTitle":18,"oldOrganization":18},"Principal Investigator",[57],{"name":58,"class":59},"Agency for Healthcare Research and Quality (AHRQ)","FED","100520015",false,"NCT06051058","Care Transitions App for Patients With Multiple Chronic Conditions","Inclusion Criteria:\n\n* Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit\n* Discharging to home, home health care service or assisted living\n* Fluent in spoken English in patient or healthcare proxy\n* Patients with at least one of the conditions listed below + one additional chronic condition on the problem list.\n* Patient with heart failure on the problem list\n* Patient with type 2 diabetes on the problem list\n* Patient with chronic kidney disease on the problem list\n\nExclusion Criteria:\n\n* Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit\n* Pregnant\n* Prisoner, institutionalized individual or in police custody\n* Discharge planned within 3 hours of screening\n* Patient too ill to participate or with active psychosis\u002Fserious mental illness, delirium, or severe dementia\n* Not fluent in spoken English in patient and health proxy\n* Unlikely to be discharged to home\n* Lacks a device capable of accessing the app\n* Lack of a working telephone for 30-day follow-up",true,"ALL","55 Years",{"count":69,"type":70},798,"ESTIMATED","INTERVENTIONAL",[73],"NA","The objective of this study is to widely implement and evaluate the Care Transitions App in a randomized controlled trial. The app the investigators designed for patients with multiple chronic conditions has four envisioned modules: 1) falls-reduction content, 2) a digital post-discharge transitional care plan (e.g., after hospital care plan, including education, medications, follow-up appointments, warning signs to watch for, nutrition, and other care plan activities), 3) a new module for patients with MCC (diabetes, congestive heart failure, and chronic kidney disease) including condition-specific post-discharge care plans with relevant symptom management activities, 4) a new post-discharge report module which summarizes key care transition findings and allows for patients to enter notes and questions for their providers and their own goals for recovery.",[76,77,78,79,80],"Heart Failure","Congestive Heart Failure","Diabetes","Diabetes Mellitus","Chronic Kidney Diseases","2025-11-12",{"date":83,"type":84},"2025-11-13","ACTUAL",{"date":86,"type":84},"2024-10-08",{"date":88,"type":70},"2026-12",{"name":5,"class":6},1]