NCT04287192 Digital Bridge: Using Technology to Support Patient-centered Care Transitions From Hospital to Home
| NCT ID | NCT04287192 |
| Status | Recruiting |
| Phase | — |
| Sponsor | Mount Sinai Hospital, Canada |
| Condition | Older Adults With Complex Care Needs |
| Study Type | INTERVENTIONAL |
| Enrollment | 640 participants |
| Start Date | 2023-04-15 |
| Primary Completion | 2026-03-30 |
Eligibility & Interventions
Eligibility Fast-Check
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What to Expect as a Participant
You will actively receive the study intervention — which may be a drug, biologic, device, or procedure.
This trial targets 640 participants in total. It began in 2023-04-15 with a primary completion date of 2026-03-30.
⚠ This information is for research awareness only. Always consult your physician before joining any clinical trial. Participation is voluntary and you may withdraw at any time.
Brief Summary
Older adults who live with multiple chronic conditions are more likely to experience frequent admissions and discharges from hospital. These transitions are often challenging and leave people at risk of readmission. Appropriate, timely and person-centred communication across all health care providers involved in transitions (in and out of hospital) as well as with patients and their families is critical to ensure a smooth and effective transition process. Digital health technologies can play an important role in improving person-centred communication across clinical settings and clinicians. This project will develop and test a Digital Bridge by connecting communication technologies already in use in hospital and primary care/community settings to improve communication between providers in hospital and in primary care, patients and family caregivers from admission to 6 months post-discharge. The investigators will engage with all the technology users to co-design the Digital Bridge, ensuring that how the investigators connect the existing technologies and adopt them into practice will meet the needs of providers, patients and their caregivers. Next hospital partners will adopt the technology into general medicine and rehabilitation services in hospital systems in Toronto (Sinai Health System) and Mississauga (Trillium Health Partners). The investigators will evaluate the Digital Bridge through a pre-post pragmatic trial, assessing impact on patient experience (quality of transition), patient outcomes (quality of life), transition processes (provider communication and teamwork), and system costs (economic evaluation). This project adopts an implementation science lens, allowing the investigators to collect qualitative data on enablers and barriers to adopting the Digital Bridge to help inform development of a scale and spread strategy.
Eligibility Criteria
Inclusion Criteria: * Patients with anticipated discharge home will be recruited at the time of admission to one of the services (i.e medicine or rehab) in the study. Patients aged 60 and over, with CCN defined as presenting with 3 or more chronic conditions from the 16 most prominent in the population, which is an established method to identifying patients with CCN. As the technology is only currently available in English, patients (or a caregiver) must be able to speak and read English. Patients with mild cognitive impairment will not be excluded if able to provide informed consent, and engage with the intervention (independently or with caregiver aid). Exclusion Criteria: * Previously participated in the study (in case of re-admission); discharge destination is another acute care facility, palliative care unit, complex continuing care, or long term care; died in hospital, cannot be contacted by telephone after discharge; unable to respond to survey question for any reason and lack of availability of family members and/or other caregivers willing and able to provide assistance.
Contact & Investigator
Carolyn Steele Gray, PhD
PRINCIPAL INVESTIGATOR
Sinai Health System
Frequently Asked Questions
Who can join the NCT04287192 clinical trial?
This trial is open to participants of all sexes, aged 60 Years or older, studying Older Adults With Complex Care Needs. Full inclusion and exclusion criteria are listed in the Eligibility Criteria section. Always confirm your eligibility with the research team before applying.
Is NCT04287192 currently recruiting?
Yes, NCT04287192 is actively recruiting participants. Contact the research team at Carolyn.SteeleGray@sinaihealth.ca for enrollment information.
Where is the NCT04287192 trial being conducted?
This trial is being conducted at Toronto, Canada.
Who is sponsoring the NCT04287192 clinical trial?
NCT04287192 is sponsored by Mount Sinai Hospital, Canada. The principal investigator is Carolyn Steele Gray, PhD at Sinai Health System. The trial plans to enroll 640 participants.