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The Care Transitions Intervention

This study has been completed.
The John A. Hartford Foundation
Information provided by (Responsible Party):
University of Colorado, Denver Identifier:
First received: October 24, 2005
Last updated: August 10, 2015
Last verified: August 2015
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 Intervention
Continuity of Patient Care
Behavioral: Care Transitions Intervention

Study Type: Interventional
Study Design: Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: Open Label
Official Title: The Care Transitions Intervention

Further study details as provided by University of Colorado, Denver:

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

Secondary Outcome Measures:
  • 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.

Estimated Enrollment: 1400
Study Start Date: September 2002
Estimated Study Completion Date: August 2003
Detailed Description:
See above.

Ages Eligible for Study:   65 Years and older   (Adult, Senior)
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.
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Please refer to this study by its identifier: NCT00244491

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
Principal Investigator: Eric A. Coleman, MD, MPH University of Colorado, Denver
  More Information

Responsible Party: University of Colorado, Denver Identifier: NCT00244491     History of Changes
Other Study ID Numbers: 00-1036
Study First Received: October 24, 2005
Last Updated: August 10, 2015

Keywords provided by University of Colorado, Denver:
care transitions
care coordination
chronic illness
patient-centered care processed this record on May 25, 2017