Care Transitions App for Patients With Multiple Chronic Conditions
Heart Failure, Congestive Heart Failure, Diabetes
About this trial
This is an interventional supportive care trial for Heart Failure
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
Sites / Locations
Arms of the Study
Arm 1
Arm 2
Experimental
No Intervention
Experimental: Care Transitions App
No Intervention: Usual Care
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.
Usual care transition care for patients hospitalized and discharged with multiple chronic conditions.