The Care Transitions Intervention

This study has been completed.

Sponsors and Collaborators:	University of Colorado at Denver and Health Sciences Center The John A. Hartford Foundation
Information provided by:	University of Colorado at Denver and Health Sciences Center
ClinicalTrials.gov Identifier:	NCT00244491

Purpose

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

U.S. FDA Resources

Study Type:	Interventional
Study Design:	Educational/Counseling/Training, Randomized, Open Label, Active Control, Single Group Assignment, Efficacy Study
Official Title:	The Care Transitions Intervention

Further study details as provided by University of Colorado at Denver and Health Sciences Center:

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.

Eligibility

Ages Eligible for Study:	65 Years and older
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No

Criteria

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.

Contacts and Locations

Please refer to this study by its ClinicalTrials.gov identifier: NCT00244491

Locations

United States, Colorado
University of Colorado Health Sciences Center
Denver, Colorado, United States, 80262

Sponsors and Collaborators

University of Colorado at Denver and Health Sciences Center

The John A. Hartford Foundation

Investigators

Principal Investigator:

Eric A. Coleman, MD, MPH

University of Colorado at Denver and Health Sciences Center

More Information

Publications of Results:

Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006 Sep 25;166(17):1822-8.

Study ID Numbers:	2000-0443
Study First Received:	October 24, 2005
Last Updated:	November 29, 2006
ClinicalTrials.gov Identifier:	NCT00244491
Health Authority:	United States: Food and Drug Administration

Keywords provided by University of Colorado at Denver and Health Sciences Center:

care transitions
geriatric
care coordination

self-management
chronic illness
patient-centered care

Study placed in the following topic categories:

Chronic Disease

ClinicalTrials.gov processed this record on January 16, 2009