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Can better hospital discharge planning keep seniors out of the ER?

NCT ID NCT04212962

Disease control Sponsor: Mathematica Policy Research, Inc. Source: ClinicalTrials.gov ↗

What the study statuses mean

This study's is highlighted.

Recruitment status, easiest to join first

Recruiting now
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 This study
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 Results may not be published yet.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This status has not been confirmed recently, so it may be out of date.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 Jul 08, 2026 · Last updated Jul 09, 2026 · Updated 1 time

Summary

This study tests a transitional care model for older adults (65+) hospitalized with heart failure, COPD, or pneumonia. The model provides extra education, social services, and coordination among doctors after discharge. Researchers compare this to usual care to see if it reduces hospital readmissions and costs over the next year.

What this could mean

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

Active substance
transitional care model (patient education, social services coordination, medical information sharing)
What this could lead to
If effective, this approach could reduce hospital readmissions and improve recovery for older adults with serious conditions like heart failure or COPD.
What could go wrong
This is a behavioral intervention, not a drug or device, so results may vary across hospitals and patient groups. It may not reduce readmissions as hoped.

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

962 people

The number who actually took part.

Started

Jul 2020

Expected to finish

Dec 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

65 years and older

Sex

Anyone

Healthy volunteers

Not accepted

This study is not open to healthy volunteers. The entry requirements below say who it is open to.

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: * Age 65 years and older * Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis * English and non-English speaking, able to respond to questions * Reachable by telephone after discharge * Resides within the geographic service area * Consent to participation Exclusion Criteria: * Enrolled in Medicare's Hospice or End-Stage Renal Disease programs * Presence of active and untreated psychiatric conditions (ICD10: F10-F29) * Long-term care resident * Undergoing active cancer treatment * Currently enrolled in another RCT

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Conditions

The condition(s) this trial relates to.

chronic obstructive pulmonary disease congestive heart failure COPD, severe early onset heart failure pneumonia

As listed by the trial registrant

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

CHF - congestive heart failure COPD Pneumonia

Contacts and locations

Locations

  • Mathematica Policy Research

    Princeton, New Jersey, 08540, United States

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