Can asking patients about their needs reduce hospital visits?
NCT ID NCT05820295
First seen Jun 26, 2026 · Last updated Jul 24, 2026 · Updated 2 times
Summary
This study looked at two ways to assign care coordinators to older adults (65+) with heart disease or risk factors. One method used patients' own reports of difficulty coordinating care, while the other used usual triggers like hospital discharge. The goal was to see which approach better reduced emergency room visits and hospitalizations. The trial involved 400 Medicare beneficiaries and was completed in a real-world healthcare setting.
What this could mean
Our plain-language read of the trial. This is informational only, not medical advice or a prediction.
- Active substance
- care coordination (behavioral intervention)
- What this could lead to
- If successful, this could show that assigning care coordinators based on patients' own reports of difficulty is better than the usual method, potentially reducing hospital visits.
- What could go wrong
- This is a completed pragmatic trial, so results are available but may not apply to all healthcare systems. The intervention is behavioral, not a drug, so benefits may be modest.
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
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400 people
The number who actually took part.
- Started
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May 2023
- Finished
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Jul 2024
- Lead sponsor
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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
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65 years and older
- Sex
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Anyone
- Healthy volunteers
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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 Hide 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: * Medicare beneficiaries 65 years and older, * Attributed to the NewYork Quality Care accountable care organization, * Are community-dwelling, * Have cardiovascular disease or 1 or more cardiovascular risk factors, and * Had highly fragmented ambulatory care in the prior year (defined as a reversed Bice-Boxerman Index greater than or equal to 0.85) Exclusion Criteria: * Those who reside in long-term care or nursing home facilities (based on addresses in Medicare claims) * Enrolled in home hospice * Dementia (as measured in claims using the Bynum Standard 1-year definition)
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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
Locations
-
New York Presbyterian Hospital - Weill Cornell Medicine
New York, New York, 10065, United States
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