Can better hospital discharge planning keep seniors out of the ER?
NCT ID NCT04212962
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.
Get updates
Get notified about this study
Sign up to get updates when this study changes or when new studies for CHF - CONGESTIVE HEART FAILURE are added.
By submitting, you agree to our Terms of use
Conditions
The condition(s) this trial relates to.
As listed by the trial registrant
The condition terms exactly as the trial's registrant entered them.
Contacts and locations
Show contact details
Enter your email to view the contact information for this study.
By submitting, you agree to our Terms of use
Locations
-
Mathematica Policy Research
Princeton, New Jersey, 08540, United States
More trials for these conditions
Other studies related to the condition(s) this trial covers.
- A handheld device that vibrates the airways may help COPD patients breathe easier
- Can scientists unlock the secrets of breathing muscle failure in severe COPD?
- Which exercise is better for the COPD brain? scientists compare steady vs. burst workouts
- Diabetes drugs may shield against severe pneumonia outcomes
- Your voice could hold the key to spotting lung disease
- Blood tests could unlock early clues for three major lung diseases