- Conditions
- Hospital Readmission, Post-discharge Care Transitions, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease
- Interventions
- Patient Navigator, Usual care
- Other
- Lead sponsor
- Alison Galbraith
- Other
- Eligibility
- 18 Years and older
- Enrollment
- 1,510 participants
- Healthy volunteers
- Healthy volunteers not accepted
- Timeline
- 2011 – 2013
- U.S. locations
- 2
- States / cities
- Cambridge, Massachusetts • Everett, Massachusetts
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- Conditions
- Low Back Pain, Neck Pain
- Interventions
- Engagement of clinic leadership (System Intervention - Usual Care), Engagement of clinic leadership (System Intervention - STEPPT), Patient Registry (System Intervention - STEPPT), Delivery of Patient Education Materials (System Intervention - Usual Care), Delivery of Patient Education Materials (System Intervention - STEPPT), Referral Specialist Training (System Intervention - Usual Care), Patient Health Navigator Training (System Intervention - STEPPT), Care Navigation (System Intervention - STEPPT), Care navigation audit and feedback (System Intervention - STEPPT), Primary Care Provider training (Provider Intervention - STEPPT), Nurse/Medical Assistant Training (Provider Intervention - STEPPT), Provider feedback on PT referral and adherence (Provider Intervention - STEPPT), Patient education on spine pain condition (Patient Intervention - Usual Care), Patient education on spine pain condition (Patient Intervention - STEPPT), Patient Education on Physical Referral by Providers (Patient Intervention - Usual Care), Patient Education on Physical Referral by Providers (Patient Intervention - STEPPT), Electronic Patient Education on Physical Therapy Referral (Patient Intervention - STEPPT), Patient education on physical therapy referral by Referral Specialist (Patient Intervention - Usual Care), Patient education on physical therapy referral by Patient Health Navigator (Patient Intervention - STEPPT), Care Navigation (System Intervention - Usual Care), Monitoring of PT referral and adherence rates (System Intervention - STEPPT), Monitoring of PT referral and adherence rates (System intervention - Usual Care)
- Behavioral
- Lead sponsor
- San Diego State University
- Other
- Eligibility
- 18 Years and older
- Enrollment
- 17,587 participants
- Healthy volunteers
- Healthy volunteers not accepted
- Timeline
- 2025 – 2029
- U.S. locations
- 1
- States / cities
- San Diego, California
- Conditions
- Dementia
- Interventions
- Dementia Care Management
- Behavioral
- Lead sponsor
- Corporal Michael J. Crescenz VA Medical Center
- Federal
- Eligibility
- 18 Years and older
- Enrollment
- 75 participants
- Healthy volunteers
- Accepts healthy volunteers
- Timeline
- 2011 – 2014
- U.S. locations
- 1
- States / cities
- Philadelphia, Pennsylvania
- Conditions
- Uncontrolled Hypertension
- Interventions
- Provider Audit-Feedback, Stratified by Race and Ethnicity, Blood Pressure Measurement Standardization, System Level Leadership Intervention, Collaborative Care Team Intervention, Community Health Worker Referral, Specialist Care Consultation
- Behavioral
- Lead sponsor
- Johns Hopkins University
- Other
- Eligibility
- 21 Years to 100 Years
- Enrollment
- 1,820 participants
- Healthy volunteers
- Accepts healthy volunteers
- Timeline
- 2017 – 2022
- U.S. locations
- 1
- States / cities
- Baltimore, Maryland
- Conditions
- Colorectal Cancer, Comprehensive Transitional Care Program
- Interventions
- Patient education: One-on-one visit, Discharge planning: Assessment of barriers to discharge, Medication reconciliation: Patient medication review, Appointment before discharge: Additional measure to ensure awareness of next clinic visit, Transition coach, Patient-centered discharge instructions: Enhanced, Provider continuity: Specific surgeons responsible for coordinating care with medical/radiation oncology, Timely follow-up: Barriers to clinic follow-up visits will be discussed, Timely PCP communication, Follow-up telephone call, Patient hotline: 24 hour follow-up following call to Ask My Nurse number
- Other
- Lead sponsor
- The University of Texas Health Science Center, Houston
- Other
- Eligibility
- 18 Years and older
- Healthy volunteers
- Healthy volunteers not accepted
- Timeline
- Started 2015
- U.S. locations
- 1
- States / cities
- Houston, Texas