An interventional study of Transitional care model (TCM) and Usual care in CHF - Congestive Heart Failure, COPD and Pneumonia, sponsored by Mathematica Policy Research, Inc.. Active, not recruiting at 1 site in United States. Open to participants aged 65 Years and older. Per ClinicalTrials.gov, last updated 2026-07-08.
Sponsored by Mathematica Policy Research, Inc. · Not applicable, Interventional, and Health services research
The study is a randomized controlled trial to estimate the effects of the transitional care model (TCM) on hospital admissions and patients' experience during the year following the patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will be the coordinating center for the implementation. The study will be conducted in three large health systems spread throughout the U.S., drawing patients from seven hospitals in those systems. Eligible patients are older adults (age 65 and older) admitted to a participating hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia (PNA). The evaluation will be conducted by Mathematica.
The Transitional Care Model (TCM) is an advanced practice registered nurse (APRN) led, team-based, care management strategy designed to improve the care and outcomes of high-risk older adults transitioning from hospital to home. Eligible patients who agree to participate in the study will be randomly assigned to either the intervention group, which receives the TCM intervention, or the control group, which receives usual care (standard hospital discharge planning and post-hospital follow up services). The target sample size for the study is close to 1000, evenly divided into intervention and control groups, with 250 to 270 patients derived from each of UCSF and Trinity health systems, and another 450 recruited from the two VHA hospitals combined. Data will be collected at intake, prior to randomization, by enrollment coordinators at each of the participating hospitals. Followup data will be collected in a survey of patients conducted 90 days after discharge, and from claims data obtained from Medicare, Medicare Advantage plans, and the VHA.
Exclusion Criteria:
The treatment group receives the TCM intervention while in the hospital and during the first 90 days after returning to the community.
Behavioral: Transitional care model (TCM)
The control group receives usual discharge planning and post-discharge care.
Behavioral: Usual care
Patient education about post-discharge self-care and medications, arrangement of needed social services, coordination of information from medical providers interacting with patient
usual hospital discharge and post-discharge care
Number of hospital admissions
number of times admitted to the hospital during 12 months after initial discharge
Time frame: 12 months
Costs
Costs of medical care paid for by Medicare, Medicare Advantage plan, or Veterans Health Administration
Time frame: 12 months
30-day readmission
whether readmitted to a hospital during the 30 days after initial discharge
Time frame: 30 days
emergency department visits
number of times treated in an emergency department after initial discharge
Time frame: 12 months
length of time to death or hospital admission
number of days between initial discharge and either death or readmission to hospital
Time frame: 12 months after initial discharge
Skilled nursing facility days
Number of days spent in a skilled nursing facility
Time frame: 12 months after initial discharge
Mortality
whether died after initial discharge
Time frame: 12 months after initial discharge
Edmonton Symptom Assessment Scale
measures post-hospital symptoms, range 0-100, high score is bad
Time frame: 90 days after initial discharge
Patient-Reported Outcomes Measurement Information System Physical Functioning (SF10a)
functional status, range 10-50, high score is good
Time frame: 90 days after initial discharge
Patient Health Questionnaire for Depression and Anxiety (PHQ-4)
index of depression and anxiety, range 0-12, high score is bad
Time frame: 90 days after initial discharge
Plan to share: No
This study is active, not recruiting, as verified in Jul 2026. You cannot join it, but the record below documents what was studied.
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Mathematica Policy Research, Inc.