Care Transitions App for Patients With Multiple Chronic Conditions

Launched by BRIGHAM AND WOMEN'S HOSPITAL · Sep 18, 2023

Keywords

ClinConnect Summary

The Care Transitions App study is looking to help patients with multiple chronic conditions, such as heart failure, diabetes, and chronic kidney disease, manage their health better after leaving the hospital. The app includes features to help reduce falls, create personalized care plans for after hospital discharge, and provide information on managing symptoms related to their conditions. Patients will also be able to share their notes and questions with their healthcare providers, helping them stay on track with their recovery.

To participate in this study, you must be an adult aged 55 or older, currently receiving care from a specific doctor at Brigham and Women’s Hospital, and have at least one of the listed chronic conditions along with another. You should also be able to speak English and have a device to use the app. Those who are pregnant, have serious mental health issues, or are being discharged to places other than home may not be eligible. If you join the study, you can expect to use the app to help manage your health after leaving the hospital and to receive support tailored to your specific needs.

Gender

ALL

Eligibility criteria

• Inclusion Criteria:
• • Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit
• • Discharging to home, home health care service or assisted living
• • Fluent in spoken English in patient or healthcare proxy
• • Patients with at least one of the conditions listed below + one additional chronic condition on the problem list.
• • Patient with heart failure on the problem list
• • Patient with type 2 diabetes on the problem list
• • Patient with chronic kidney disease on the problem list
• Exclusion Criteria:
• • Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit
• • Pregnant
• • Prisoner, institutionalized individual or in police custody
• • Discharge planned within 3 hours of screening
• • Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia
• • Not fluent in spoken English in patient and health proxy
• • Unlikely to be discharged to home
• • Lacks a device capable of accessing the app
• • Lack of a working telephone for 30-day follow-up