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ClinicalTrials.gov public records Last synced Oct 30, 2026, 6:01 PM EDT

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Showing 1–24 of 83 matching trials from the live ClinicalTrials.gov search.
Filters: Condition: Transitions of Care Clear all
Completed Not applicable Interventional Results available

Supplement to Hospital to Home Outcomes

NCT03224130
View directory record Official record
Conditions
Hospitalized Patients
Interventions
Nurse Phone Call, Standard of Care
Other
Lead sponsor
Children's Hospital Medical Center, Cincinnati
Other
Eligibility
Up to 18 Years
Enrollment
966 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2016 – 2017
U.S. locations
1
States / cities
Cincinnati, Ohio
Source: ClinicalTrials.gov public record
Updated Apr 16, 2019 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Pharmacist-led Transitions of Care in the Outpatient Oncology Infusion Center for Patients With Solid Tumor

NCT04122118
View directory record Official record
Conditions
Malignant Solid Neoplasm
Interventions
Medical Chart Review, Educational Intervention, Survey Administration
Other
Lead sponsor
Thomas Jefferson University
Other
Eligibility
18 Years to 85 Years
Enrollment
26 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2019 – 2021
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Apr 29, 2025 · Synced Oct 30, 2026, 6:01 PM EDT
Enrolling by invitation No phase listed Observational

Epilepsy Emergency Department High Utilizer Program

NCT07663240
View directory record Official record
Conditions
Epilepsy, Uncontrolled Seizures
Interventions
CHW-Led Transition-of-Care Intervention
Behavioral
Lead sponsor
Morehouse School of Medicine
Other
Eligibility
18 Years and older · Female only
Enrollment
15 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2026
U.S. locations
1
States / cities
Atlanta, Georgia
Source: ClinicalTrials.gov public record
Updated Jun 23, 2026 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Connect-Home Clinical Trial

NCT03810534
View directory record Official record
Conditions
Transitional Care, Caregivers, Patient Discharge, Aging, Frailty
Interventions
Connect-Home
Behavioral
Lead sponsor
University of North Carolina, Chapel Hill
Other
Eligibility
18 Years and older
Enrollment
654 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2019 – 2021
U.S. locations
1
States / cities
Chapel Hill, North Carolina
Source: ClinicalTrials.gov public record
Updated Aug 23, 2022 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Structured Handoff Using Intelligent Framework for Transitions Trial

NCT07251907
View directory record Official record
Conditions
Electronic Medical Record, Transitions of Care, Physician Workflow, Artificial Intelligence (AI), Large Language Model
Interventions
LLM tool to draft handoff
Other
Lead sponsor
University of Pennsylvania
Other
Eligibility
18 Years and older
Enrollment
85 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2025 – 2026
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Jun 2, 2026 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Evaluation of Transitions Clinic: A Post-Release Clinic for Recently Released Parolees With Chronic Medical Conditions

NCT01179035
View directory record Official record
Conditions
Health Services Research, Prisons, Delivery of Health Care, Vulnerable Populations, Community Health Aides
Interventions
Transitions Clinic - parolee-targeted care, Expedited Primary Care
Other
Lead sponsor
Transitions Clinic
Other
Eligibility
18 Years and older
Enrollment
150 participants
U.S. locations
1
States / cities
San Francisco, California
Source: ClinicalTrials.gov public record
Updated Aug 10, 2010 · Synced Oct 30, 2026, 6:01 PM EDT
Terminated Not applicable Interventional

Transitions of Care Clinic (TOCC)

NCT06937827
View directory record Official record
Conditions
Heart Failure With Preserved Ejection Fraction
Interventions
HF Kit and Follow-ups
Behavioral
Lead sponsor
Hackensack Meridian Health
Other
Eligibility
18 Years to 90 Years
Enrollment
69 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2025 – 2026
U.S. locations
1
States / cities
Brick, New Jersey
Source: ClinicalTrials.gov public record
Updated Sep 21, 2026 · Synced Oct 30, 2026, 6:01 PM EDT
Not yet recruiting Not applicable Interventional

MEDBRIDGE-Guided NCM/CHW Post-Discharge Support for High-Risk T2D Patients

NCT07599852
View directory record Official record
Conditions
Type 2 Diabetes, Medication Adherence, Care Transition, Medication Discrepancy
Interventions
MEDBRIDGE-Guided NCM/CHW Post-Discharge Support Intervention
Behavioral
Lead sponsor
University of Alabama at Birmingham
Other
Eligibility
18 Years and older
Enrollment
45 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2029 – 2031
U.S. locations
2
States / cities
Birmingham, Alabama
Source: ClinicalTrials.gov public record
Updated May 20, 2026 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Hospital to Home Outcomes

NCT02081846
View directory record Official record
Conditions
Focus: Hospitalized Patients
Interventions
Nurse Home Visit, Standard of Care
Other
Lead sponsor
Children's Hospital Medical Center, Cincinnati
Other
Eligibility
Up to 18 Years
Enrollment
1,500 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2015 – 2017
U.S. locations
1
States / cities
Cincinnati, Ohio
Source: ClinicalTrials.gov public record
Updated Apr 16, 2019 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Care Transition Intervention for Patients With Cancer

NCT04640714
View directory record Official record
Conditions
Advanced Cancer, Home Care, Hospital-Based
Interventions
CONTINUity of care Under Management by Video visits (CONTINUUM-V)
Behavioral
Lead sponsor
Massachusetts General Hospital
Other
Eligibility
18 Years and older
Enrollment
58 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2021
U.S. locations
1
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Nov 19, 2021 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Relative Patient Benefits of a Hospital-PCMH Collaboration Within an ACO to Improve Care Transitions

NCT02130570
View directory record Official record
Conditions
Adverse Events, Readmissions, Patient Engagement
Interventions
Multi-Model Intensive Discharge Intervention
Other
Lead sponsor
Brigham and Women's Hospital
Other
Eligibility
18 Years and older
Enrollment
1,679 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2013 – 2015
U.S. locations
2
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Aug 20, 2019 · Synced Oct 30, 2026, 6:01 PM EDT
Terminated Phase 4 Interventional Results available

Nebulizer Versus Dry Powdered Inhalers for Chronic Obstructive Pulmonary Disease (COPD)

NCT03219866
View directory record Official record
Conditions
COPD, COPD Exacerbation
Interventions
Nebulizers, Dry Powder Inhaler, Brovana, Pulmicort, Atrovent, Advair Diskus, Spiriva HandiHaler
Device · Drug
Lead sponsor
Wake Forest University Health Sciences
Other
Eligibility
40 Years and older
Enrollment
40 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2017 – 2020
U.S. locations
1
States / cities
Winston-Salem, North Carolina
Source: ClinicalTrials.gov public record
Updated Jun 22, 2021 · Synced Oct 30, 2026, 6:01 PM EDT
Active, not recruiting Not applicable Interventional

The Transitions Project: Efficacy Trial

NCT05087251
View directory record Official record
Conditions
Lung Cancer
Interventions
Five Psycho-educational Session(s), One Psycho-educational Session(s)
Behavioral
Lead sponsor
Massachusetts General Hospital
Other
Eligibility
21 Years and older
Enrollment
100 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2021 – 2026
U.S. locations
2
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Mar 30, 2026 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Testing the Efficacy of a Post-discharge Call Program on the Rate of Readmission

NCT03683797
View directory record Official record
Conditions
Care Transitions
Interventions
Post-discharge call
Other
Lead sponsor
NYU Langone Health
Other
Eligibility
Not listed
Enrollment
3,267 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2018 – 2019
U.S. locations
1
States / cities
New York, New York
Source: ClinicalTrials.gov public record
Updated Jul 20, 2021 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Improving Patient Prioritization During Hospital-homecare Transition

NCT04136951
View directory record Official record
Conditions
Diabetes Mellitus, Type 2, Congestive Heart Failure, Obstructive Pulmonary Disease, Dyspnea, Renal Failure
Interventions
PREVENT clinical decision support
Other
Lead sponsor
Columbia University
Other
Eligibility
18 Years and older
Enrollment
1,915 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2023 – 2024
U.S. locations
2
States / cities
New York, New York
Source: ClinicalTrials.gov public record
Updated Oct 8, 2025 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Accepts healthy volunteers

Interactive Digital Health Tools to Improve Patient Safety in Acute Care

NCT03116074
View directory record Official record
Conditions
Transitions of Care, Patient Portals, General Medicine, Discharge Checklist, Patient-provider Communication, Adverse Event, Readmission
Interventions
Interactive Digital Health Tools
Behavioral
Lead sponsor
Brigham and Women's Hospital
Other
Eligibility
18 Years and older
Enrollment
750 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2017 – 2020
U.S. locations
1
States / cities
Boston, Massachusetts
Source: ClinicalTrials.gov public record
Updated Jul 25, 2022 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Improving Coordination and Transitions of Care in Stroke Patients

NCT02642744
View directory record Official record
Conditions
Stroke, Transient Ischemic Attack
Interventions
Nursing care model
Other
Lead sponsor
University of Pennsylvania
Other
Eligibility
18 Years and older
Enrollment
670 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2015 – 2023
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Feb 23, 2024 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

Improving Morbidity During Post-Acute Care Transitions for Sepsis

NCT03865602
View directory record Official record
Conditions
Clinical Sepsis
Interventions
Sepsis Transition And Recovery (STAR), Usual care
Behavioral
Lead sponsor
Wake Forest University Health Sciences
Other
Eligibility
18 Years and older
Enrollment
712 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2019 – 2021
U.S. locations
1
States / cities
Charlotte, North Carolina
Source: ClinicalTrials.gov public record
Updated Apr 25, 2022 · Synced Oct 30, 2026, 6:01 PM EDT
Completed No phase listed Observational Accepts healthy volunteers

Empowering Youth Aging Out of Foster Care

NCT04895670
View directory record Official record
Conditions
Health Behavior
Interventions
Empowering Youth Aging out of Foster Care
Behavioral
Lead sponsor
University of Texas Southwestern Medical Center
Other
Eligibility
18 Years to 65 Years
Enrollment
50 participants
Healthy volunteers
Accepts healthy volunteers
Timeline
2021 – 2023
U.S. locations
1
States / cities
Dallas, Texas
Source: ClinicalTrials.gov public record
Updated Aug 29, 2023 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

MORE-PC: A 30-day Automated SMS Program to Support Post-discharge Transitions of Care

NCT05245773
View directory record Official record
Conditions
Care Transitions
Interventions
Automated SMS program to support post-discharge transitions of care
Other
Lead sponsor
University of Pennsylvania
Other
Eligibility
18 Years and older
Enrollment
5,000 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2022 – 2023
U.S. locations
1
States / cities
Philadelphia, Pennsylvania
Source: ClinicalTrials.gov public record
Updated Feb 27, 2023 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional

GAPcare: The Geriatric Acute & Post-acute Care Coordination Program for Fall Prevention in the Emergency Department

NCT03360305
View directory record Official record
Conditions
Falls (Accidents) in Old Age
Interventions
GAPcare intervention
Behavioral
Lead sponsor
Rhode Island Hospital
Other
Eligibility
65 Years and older
Enrollment
110 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2018 – 2019
U.S. locations
2
States / cities
Providence, Rhode Island
Source: ClinicalTrials.gov public record
Updated Jul 9, 2020 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Not applicable Interventional Results available

Home Based Care Transitions Tailored by Cognition and Patient Activation

NCT02045147
View directory record Official record
Conditions
Chronic Disease
Interventions
Grp 1a Low Cognition, Low Activation Intervention, Grp 2a Low Cognition, High Activation Intervention, Grp 3a Normal Cognition, Low Activation Intervention, Grp 4a Normal Cognition, High Activation Intervention
Behavioral
Lead sponsor
University of Nebraska
Other
Eligibility
19 Years and older
Enrollment
263 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2013 – 2014
U.S. locations
1
States / cities
Lincoln, Nebraska
Source: ClinicalTrials.gov public record
Updated Oct 8, 2024 · Synced Oct 30, 2026, 6:01 PM EDT
Completed Phase 4 Interventional

DHFS for Medication Adherence Support During Hospital Admissions for Person Living With HIV

NCT04418037
View directory record Official record
Conditions
HIV/AIDS
Interventions
Digital Health Feedback System(DHFS)
Device
Lead sponsor
University of California, San Diego
Other
Eligibility
18 Years and older
Enrollment
16 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2019 – 2021
U.S. locations
1
States / cities
San Diego, California
Source: ClinicalTrials.gov public record
Updated Dec 16, 2024 · Synced Oct 30, 2026, 6:01 PM EDT
Not yet recruiting Not applicable Interventional

Comprehensive Enhanced Care Management Under CalAIM for High-Risk Medi-Cal Members

NCT07587073
View directory record Official record
Conditions
Complex Care, Post-Acute Care Utilization, Housing Instability, Residential Care Transition, Population Health Management, Care Transitions
Interventions
Comprehensive CalAIM Care Bundle, Usual CalAIM Service Delivery
Behavioral · Other
Lead sponsor
StratiHealth
Industry
Eligibility
18 Years and older
Enrollment
1,200 participants
Healthy volunteers
Healthy volunteers not accepted
Timeline
2026 – 2028
U.S. locations
1
States / cities
Los Angeles, California
Source: ClinicalTrials.gov public record
Updated May 14, 2026 · Synced Oct 30, 2026, 6:01 PM EDT