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ClinicalTrials.gov public records Last synced Oct 21, 2026, 5:58 AM EDT

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Showing 1–24 of 143 matching trials from the live ClinicalTrials.gov search.
Filters: Condition: Transition of Care Clear all
Recruiting Phase 2 Interventional

Cognitive Remediation Intervention to Prepare for Transition of Care

NCT05336201
View directory record Official record
Conditions
Sickle Cell Disease, Cognitive Impairment, Adolescent Behavior, Self Efficacy, Health-Related Behavior, Coping Skills
Interventions
CREADY (Cognitive-Remediation of Executive and Adaptive Deficits in Youth)
Behavioral
Lead sponsor
University of Alabama at Birmingham
Other
Eligibility
10 Years to 18 Years
Enrollment
120 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2022 – 2027
U.S. locations
1
States / cities
Birmingham, Alabama
Source: ClinicalTrials.gov public record
Updated Feb 27, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional Accepts healthy volunteers

Using Health Information Technology (HIT) to Improve Transitions of Complex Elderly Patients From Skilled Nursing Facility (SNF) to Home

NCT01004328
View directory record Official record
Conditions
Adverse Outcomes
Interventions
Intervention 1: Electronic medical record (EMR)-based transitional care intervention
Other
Lead sponsor
University of Massachusetts, Worcester
Other
Eligibility
65 Years and older
Enrollment
626 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2011 – 2013
U.S. locations
1
States / cities
Worcester, Massachusetts
Source: ClinicalTrials.gov public record
Updated Apr 24, 2014 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Use of a Brief Phone Call After ED Discharge

NCT01893931
View directory record Official record
Conditions
Discharge Planning, Emergency Medicine, Geriatrics, Patient Readmission
Interventions
ED Discharge & Medication Call, Placebo Comparator
Behavioral
Lead sponsor
University of North Carolina, Chapel Hill
Other
Eligibility
65 Years and older
Enrollment
2,003 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2013 – 2016
U.S. locations
1
States / cities
Chapel Hill, North Carolina
Source: ClinicalTrials.gov public record
Updated Jul 11, 2016 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional Results available

Feasibility Testing of Patient Reported Outcomes - Informed Symptom Management System (PRISMS)

NCT04492007
View directory record Official record
Conditions
Colorectal Cancer, Bladder Cancer, Ovarian Cancer, Cervical Cancer, Uterine Cancer
Interventions
Patient-Reported Outcomes-Informed Symptom Management System (PRISMS)
Behavioral
Lead sponsor
UNC Lineberger Comprehensive Cancer Center
Other
Eligibility
18 Years to 99 Years
Enrollment
46 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2020 – 2021
U.S. locations
1
States / cities
Chapel Hill, North Carolina
Source: ClinicalTrials.gov public record
Updated Feb 3, 2025 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

IMPaCT (Individualized Management Towards Patient-Centered Targets)

NCT01346462
View directory record Official record
Conditions
General Medical Inpatient Conditions
Interventions
Patient-Centered Transition Intervention
Behavioral
Lead sponsor
University of Pennsylvania
Other
Eligibility
18 Years to 65 Years
Enrollment
513 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2011 – 2012
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated May 1, 2014 · Synced Oct 21, 2026, 5:58 AM EDT
Not listed No phase listed Observational Accepts healthy volunteers

Congenital Heart Initiative-Redefining Outcomes and Navigation to Adult Centered Care

NCT05185232
View directory record Official record
Conditions
Congenital Heart Disease, Comorbidities and Coexisting Conditions
Interventions
Impact of gaps in care/loss to healthcare follow-up
Other
Lead sponsor
Children's National Research Institute
Other
Eligibility
18 Years and older
Enrollment
3,000 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2022 – 2024
U.S. locations
16
States / cities
San Francisco, California • Aurora, Colorado • Washington D.C., District of Columbia + 9 more
Source: ClinicalTrials.gov public record
Updated Jan 11, 2022 · Synced Oct 21, 2026, 5:58 AM EDT
Recruiting Not applicable Interventional

Implementation of an Accessible Healthcare Model (ACHD STRONG): Comparing Nurse and Physician Lead Healthcare Transition Education in a RE-AIM Framework

NCT07559253
View directory record Official record
Conditions
Congenital Heart Disease
Interventions
Accessible Care Model Visit, Recruitment Interviews, Participating Patient-Support Person Interviews, Participating Patient-Support Person Surveys, Participating Provider Interviews and surveys, Unstructured and semi-structured interviews
Other
Lead sponsor
University of Wisconsin, Madison
Other
Eligibility
12 Years to 26 Years
Enrollment
450 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2025 – 2026
U.S. locations
1
States / cities
Madison, Wisconsin
Source: ClinicalTrials.gov public record
Updated May 5, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Recruiting Not applicable Interventional

Facilitated Transitions From Postpartum to Primary Care Coordination for People With Chronic Conditions

NCT06557005
View directory record Official record
Conditions
Hypertension, Diabetes, Postpartum, Pregnancy, Anxiety, Depression, Obesity
Interventions
Facilitated Transition to Primary Care
Other
Lead sponsor
Massachusetts General Hospital
Other
Eligibility
18 Years and older · Female only
Enrollment
1,320 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2025 – 2028
U.S. locations
1
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Jul 13, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional Accepts healthy volunteers Results available

Clinic to Community Connections - Broader Distribution

NCT04474795
View directory record Official record
Conditions
Gestational Diabetes, Gestational Diabetes Mellitus in Pregnancy
Interventions
Staff -Educational training
Behavioral
Lead sponsor
Washington University School of Medicine
Other
Eligibility
18 Years and older
Enrollment
85 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2020 – 2022
U.S. locations
1
States / cities
St Louis, Missouri
Source: ClinicalTrials.gov public record
Updated Feb 27, 2023 · Synced Oct 21, 2026, 5:58 AM EDT
Active, not recruiting Not applicable Interventional Accepts healthy volunteers

Enhancing the Care Transitions Intervention With Peer Support to Reduce Disparities

NCT04981977
View directory record Official record
Conditions
Hospital Readmissions
Interventions
Care Transitions Intervention, Care Transitions Intervention and Peer Support, Usual Care
Behavioral · Other
Lead sponsor
University of South Florida
Other
Eligibility
60 Years and older
Enrollment
483 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2022 – 2025
U.S. locations
1
States / cities
Tampa, Florida
Source: ClinicalTrials.gov public record
Updated Feb 7, 2025 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Feasibility of Using the CGM During TOC From in Persons With T2D Using Insulin

NCT04533945
View directory record Official record
Conditions
Diabetes, Type 2 Diabetes
Interventions
FreeStyle Libre
Device
Lead sponsor
Northwell Health
Other
Eligibility
18 Years and older
Enrollment
40 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2020
U.S. locations
1
States / cities
Manhasset, New York
Source: ClinicalTrials.gov public record
Updated Jan 11, 2022 · Synced Oct 21, 2026, 5:58 AM EDT
Recruiting Not applicable Interventional

Re-Engineered Discharge for Diabetes Care Transitions

NCT06869057
View directory record Official record
Conditions
Diabetes Mellitus Type 2, Social Determinants of Health (SDOH), Hospital Readmission
Interventions
REDDCAT2 Post-Discharge Navigation, Treatment as Usual (TAU)
Behavioral · Other
Lead sponsor
University of Massachusetts, Worcester
Other
Eligibility
18 Years and older
Enrollment
412 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2026 – 2029
U.S. locations
1
States / cities
Worcester, Massachusetts
Source: ClinicalTrials.gov public record
Updated Jun 30, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Recruiting Not applicable Interventional

Transition to Cardiac Rehabilitation (T2CR) to Address Barriers of Multimorbidity and Frailty

NCT06244199
View directory record Official record
Conditions
Cardiovascular Diseases, Cardiac Rehabilitation, Transition of Care
Interventions
T2CR Intervention, Usual Care
Behavioral · Other
Lead sponsor
VA Office of Research and Development
Federal
Eligibility
18 Years and older
Enrollment
250 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2024 – 2027
U.S. locations
2
States / cities
Boston, Massachusetts • Pittsburgh, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Sep 29, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Transition of Diabetes Care From Pediatric to Adult Healthcare Providers.

NCT03844126
View directory record Official record
Conditions
Transition
Interventions
Transition classes
Other
Lead sponsor
Milton S. Hershey Medical Center
Other
Eligibility
16 Years to 21 Years
Enrollment
55 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2018 – 2020
U.S. locations
1
States / cities
Hershey, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Dec 24, 2020 · Synced Oct 21, 2026, 5:58 AM EDT
Enrolling by invitation Not applicable Interventional

Telehealth Education Leveraging Electronic Transitions Of Care for COPD Patients

NCT05897125
View directory record Official record
Conditions
COPD Exacerbation, Care Transitions
Interventions
Virtual at Home Medication Reconciliation Visit(s), Virtual At Home Medication Education Visit(s), COPD advanced practice nurse Inpatient Consult, Inpatient Medication Reconciliation, Post-discharge nurse 48 hour phone follow-up call, Post-discharge follow-up advanced practice nurse outpatient visit
Other · Behavioral
Lead sponsor
University of Chicago
Other
Eligibility
18 Years and older
Enrollment
218 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2025 – 2026
U.S. locations
1
States / cities
Chicago, Illinois
Source: ClinicalTrials.gov public record
Updated Jan 14, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional Results available

Paramedic Coached ED Care Transitions to Help Older Adults Maintain Their Health

NCT02520661
View directory record Official record
Conditions
Emergencies, Aging
Interventions
Care Transitions Intervention
Behavioral
Lead sponsor
University of Wisconsin, Madison
Other
Eligibility
60 Years and older
Enrollment
1,979 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2016 – 2019
U.S. locations
2
States / cities
Rochester, New York • Madison, Wisconsin
Source: ClinicalTrials.gov public record
Updated Jul 22, 2022 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Care Transition Intervention for Hospitalized Patients With Advanced Cancer

NCT05142345
View directory record Official record
Conditions
Cancer, Follow-Up Care, Consultation, Remote, Advanced Cancer
Interventions
CONTINUUM Intervention, Usual Care
Other
Lead sponsor
Massachusetts General Hospital
Other
Eligibility
18 Years and older
Enrollment
286 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2021 – 2025
U.S. locations
1
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Oct 2, 2025 · Synced Oct 21, 2026, 5:58 AM EDT
Completed No phase listed Observational Results available

Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

NCT02354482
View directory record Official record
Conditions
Care Transitions
Interventions
Patient Communication and Care Management, Home-Based Trust, Plain Language, and Coordination, Hospital-Based Trust, Plain Language, and Coordination, Patient/Caregiver Assessment and Provider Information Exchange, Assessment and Teach Back, Standard of Care (Reference)
Behavioral · Other
Lead sponsor
Mark Williams
Other
Eligibility
18 Years and older
Enrollment
7,939 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2015 – 2019
U.S. locations
1
States / cities
Lexington, Kentucky
Source: ClinicalTrials.gov public record
Updated Nov 26, 2019 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Aiming to Improve Readmissions Through InteGrated Hospital Transitions

NCT02763202
View directory record Official record
Conditions
Hospital Readmission
Interventions
CHS Transition Services
Other
Lead sponsor
Wake Forest University Health Sciences
Other
Eligibility
18 Years and older
Enrollment
1,876 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2016 – 2017
U.S. locations
1
States / cities
Charlotte, North Carolina
Source: ClinicalTrials.gov public record
Updated Apr 27, 2022 · Synced Oct 21, 2026, 5:58 AM EDT
Enrolling by invitation Not applicable Interventional

Implementation and Evaluation of A Health Innovation to Support Medicaid-Insured Individuals Following Hospitalization

NCT05714605
View directory record Official record
Conditions
Care Transitions
Interventions
THRIVE Intervention
Behavioral
Lead sponsor
University of Pennsylvania
Other
Eligibility
18 Years to 99 Years
Enrollment
267 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2023 – 2026
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Jul 16, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional

Assessment of a Medication Reconciliation Program on Transitional Care

NCT00462059
View directory record Official record
Conditions
Hospitalization
Interventions
Treatment
Behavioral
Lead sponsor
Kaiser Permanente
Other
Eligibility
18 Years and older
Enrollment
200 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2005 – 2007
U.S. locations
1
States / cities
Aurora, Colorado
Source: ClinicalTrials.gov public record
Updated Apr 18, 2007 · Synced Oct 21, 2026, 5:58 AM EDT
Recruiting Not applicable Interventional Accepts healthy volunteers

Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers

NCT07661355
View directory record Official record
Conditions
Care Transition
Interventions
Patient-Centered Program, Family Caregiver Enhanced Program
Other
Lead sponsor
Wake Forest University Health Sciences
Other
Eligibility
18 Years and older
Enrollment
2,560 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2026 – 2031
U.S. locations
4
States / cities
Bermuda Run, North Carolina • High Point, North Carolina • North Wilkesboro, North Carolina + 1 more
Source: ClinicalTrials.gov public record
Updated Sep 21, 2026 · Synced Oct 21, 2026, 5:58 AM EDT
Not listed No phase listed Observational

Care Transitions in Renal Disease Patients

NCT01842776
View directory record Official record
Conditions
Renal Disease
Interventions
Not listed
Lead sponsor
Fresenius Medical Care North America
Industry
Eligibility
18 Years and older
Enrollment
3,300 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2013 – 2014
U.S. locations
1
States / cities
Franklin, Tennessee
Source: ClinicalTrials.gov public record
Updated Apr 30, 2013 · Synced Oct 21, 2026, 5:58 AM EDT
Completed Not applicable Interventional Results available

Respiratory Exacerbation Plans for Action and Care Transitions for Children With Severe CP

NCT05292365
View directory record Official record
Conditions
Cerebral Palsy
Interventions
RE-PACT Intervention
Behavioral
Lead sponsor
University of Wisconsin, Madison
Other
Eligibility
18 Years and older
Enrollment
60 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2022 – 2024
U.S. locations
2
States / cities
Los Angeles, California • Madison, Wisconsin
Source: ClinicalTrials.gov public record
Updated Dec 19, 2024 · Synced Oct 21, 2026, 5:58 AM EDT