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The Care Transitions Intervention

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ClinicalTrials.gov Identifier: NCT00244491
Recruitment Status : Completed
First Posted : October 26, 2005
Last Update Posted : August 13, 2015
The John A. Hartford Foundation
Information provided by (Responsible Party):
University of Colorado, Denver

Brief Summary:
This intervention tests whether encouraging older patients and their caregivers to assert a more active role in their care transitions could improve clinical outcomes. Patients are supported by a nurse transition coach and specific tools, including a Personal Health Record.

Condition or disease Intervention/treatment Phase
Continuity of Patient Care Behavioral: Care Transitions Intervention Not Applicable

Detailed Description:
See above.

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Study Type : Interventional  (Clinical Trial)
Enrollment : 1400 participants
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Official Title: The Care Transitions Intervention
Study Start Date : September 2002
Study Completion Date : August 2003

Resource links provided by the National Library of Medicine

Primary Outcome Measures :
  1. Rehospitalization rate at 30, 90 and 180 days after index hospitalization.

Secondary Outcome Measures :
  1. Rehospitalization rate at 30, 90 and 180 days after index hospitalization. Rehospitalization for the same condition as the index hospital stay, at 30, 90 and 180 days.

Information from the National Library of Medicine

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Ages Eligible for Study:   65 Years and older   (Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • To be eligible for this study, patients from the participating delivery system had to: 1) be age 65 years or older, 2) be admitted to one of the participating delivery system's contract hospitals during the study period for a non-psychiatrically-related condition, 3) be community-dwelling (i.e., not from a long-term care facility), 4) reside within a predefined geographic radius of the hospital (thereby making a home visit feasible), 5) have a working telephone, 6) be English-speaking, 7) show no documentation of dementia in the medical record, 8) have no plans to enter hospice, 9) not be participating in another research protocol, and 10) have documented in their medical record at least one of 11 diagnoses, including stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep venous thrombosis, or pulmonary embolism.

Exclusion Criteria:

  • Those who did not meet the inclusion criteria.

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00244491

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United States, Colorado
University of Colorado Health Sciences Center
Denver, Colorado, United States, 80262
Sponsors and Collaborators
University of Colorado, Denver
The John A. Hartford Foundation
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Principal Investigator: Eric A. Coleman, MD, MPH University of Colorado, Denver
Publications of Results:
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Responsible Party: University of Colorado, Denver
ClinicalTrials.gov Identifier: NCT00244491    
Other Study ID Numbers: 00-1036
First Posted: October 26, 2005    Key Record Dates
Last Update Posted: August 13, 2015
Last Verified: August 2015
Keywords provided by University of Colorado, Denver:
care transitions
care coordination
chronic illness
patient-centered care