[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"health-study-detail:100520015":3},{"organization":4,"armGroups":7,"interventions":19,"overallOfficials":25,"centralContacts":29,"locations":38,"responsibleParty":55,"collaborators":57,"id":61,"slug":18,"hasResults":62,"nctId":63,"briefTitle":64,"officialTitle":64,"acronym":18,"eligibilityCriteria":65,"healthyVolunteers":66,"sex":67,"minAge":68,"maxAge":18,"enrollmentInfo":69,"targetDuration":18,"studyType":72,"phases":73,"briefSummary":75,"conditions":76,"keywords":18,"overallStatus":40,"whyStopped":18,"lastUpdateSubmitDate":82,"lastUpdatePostDateStruct":83,"startDateStruct":86,"completionDateStruct":88,"leadSponsor":90,"locationsCount":91},{"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,"countryCode":45,"cosmosGeoPoint":46,"geoPoint":51,"contacts":52},"RECRUITING","Boston","Massachusetts","02120","United States","US",{"type":47,"coordinates":48},"Point",[49,50],-71.05977,42.35843,{"lat":50,"lon":49},[53],{"name":54,"role":31,"phone":18,"phoneExt":18,"email":33},"Lipika Samal",{"type":28,"investigatorFullName":54,"investigatorTitle":56,"investigatorAffiliation":5,"oldNameTitle":18,"oldOrganization":18},"Principal Investigator",[58],{"name":59,"class":60},"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":70,"type":71},798,"ESTIMATED","INTERVENTIONAL",[74],"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.",[77,78,79,80,81],"Heart Failure","Congestive Heart Failure","Diabetes","Diabetes Mellitus","Chronic Kidney Diseases","2025-11-12",{"date":84,"type":85},"2025-11-13","ACTUAL",{"date":87,"type":85},"2024-10-08",{"date":89,"type":71},"2026-12",{"name":5,"class":6},1]