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New tech aims to smooth Hospital-to-Home transition for seniors

NCT ID NCT04287192

Knowledge-focused Sponsor: Mount Sinai Hospital, Canada Source: ClinicalTrials.gov ↗

What the study statuses mean

This study's is highlighted.

Recruitment status, easiest to join first

Recruiting now This study
This trial is taking on new participants right now.
Not yet recruiting
Registered, but not yet taking participants.
By invitation only
Not open to general applications. Only people the study team invites can take part.
Paused
Paused for now. It may or may not start again.
Ongoing
Running, but no longer taking on new participants.
Completed
The trial has finished. Results may not be published yet.
Stopped early
Stopped early, before it reached the end. That can be for many reasons, including safety.
Cancelled
Cancelled before anyone took part.

Expanded access (not trials)

Expanded access
Not a trial. This treatment can be requested outside a study, case by case, for people who qualify.
Expanded access (paused)
Not a trial. The treatment can normally be requested outside a study, but is unavailable right now.
Expanded access (ended)
Not a trial. The treatment could once be requested outside a study, but no longer can.
Approved
The treatment has been approved, so it is available normally rather than through this programme.

When the status isn't known

Details not published
The full record has not been published yet, so there is little to show here.
Status unknown
This status has not been confirmed recently, so it may be out of date.

First seen Jun 25, 2026 · Last updated Jun 27, 2026 · Updated 1 time

Summary

This study tests a digital tool called the Digital Bridge, which connects hospital and primary care communication systems to improve care transitions for older adults with multiple chronic conditions. Researchers will enroll 640 patients aged 60 and older from two hospital systems in Toronto and Mississauga. The goal is to see if better communication between providers, patients, and caregivers can improve transition quality and reduce readmissions.

What this could mean

Our plain-language read of the trial. This is informational only, not medical advice or a prediction.

Active substance
Digital Bridge (Care Connector and ePRO technologies)
What this could lead to
If successful, this could improve care transitions for older adults, reducing hospital readmissions and enhancing quality of life.
What could go wrong
This is a pragmatic pre-post study, not a randomized controlled trial, so results may be influenced by other factors. The technology is only available in English, limiting generalizability.

This is an AI summary of the original study and may miss details. Read our disclaimer.

Study facts

What this study's own registry entry says, in plain language.

Phase

Not a phased trial

Phase numbers describe drug development. The registry uses this when they do not apply, as it does for trials of devices, procedures or behaviour changes, and for observational studies.

Participants

About 640 people

The number the study aims to enrol. It can still change while the study runs.

Started

Apr 2023

Expected to finish

Mar 2026

An estimate. End dates often move.

Lead sponsor

Other sponsor

The registry's catch-all category, for sponsors it does not file as a company, a government agency, or a research network.

Who can take part

This study's own entry requirements. Only the study team can say for certain whether you qualify.

Ages

60 years and older

Sex

Anyone

Healthy volunteers

Accepted

You do not need to have the condition being studied to take part.

Show the full entry requirements

Copied word for word from the study's registry entry, so the wording is the study team's rather than ours.

Inclusion Criteria: * Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid). Exclusion Criteria: * Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance.

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As listed by the trial registrant

The condition terms exactly as the trial's registrant entered them.

Older adults with complex care needs

How to take part

Only the study team decides who joins. These are the ways to reach them.

  1. The places running it

    1 site. The list below names each one and where it is.

  2. The official record

    ClinicalTrials.gov lists the study team's own contact details, including names and phone numbers. We don't republish those.

    Open the record ↗

  3. A doctor treating you

    A doctor who knows your case can contact a study site on your behalf, and can tell you whether this study is worth pursuing at all.

Contacts and locations

Locations

  • Sinai Health

    RECRUITING

    Toronto, Ontario, M5G 1X5, Canada