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.
6,331 studies on the registry are indexed under Heart Failure; 1,396 are open to participants now.
This study's enrollment of 962 is above the median of 76 across 4,049 interventional studies indexed under Heart Failure.
Browse Heart Failure studies →Mathematica Policy Research, Inc. is the lead sponsor of 49 studies on the registry; 3 are open to participants now.
Counted across the registry records on this site, refreshed daily.
Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.
Exclusion Criteria:
Underlined terms in the criteria open these too. Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
Chronic obstructive pulmonary disease: long-term lung disease that makes it hard to breathe out, including emphysema and chronic bronchitis.
COPD
Chronic obstructive pulmonary disease: long-term lung disease that makes it hard to breathe out, including emphysema and chronic bronchitis.
Explained by clinicaltrials.gg, not part of the registry record. The study team decides who can take part.
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
Ran from Jul 2020 to primary completion in Jul 2024, 48 months.
Of 1,118 non-industry interventional studies with no phase under Heart Failure, half reached primary completion within 29 months of starting (the median), counting those still running; a quarter within 16 and three quarters within 50. This study's 48 months is above that.
Counting every sponsor, half of 1,354 studies reached it within 31 months; a quarter within 16 and three quarters within 52.
How these figures are worked out, and which studies are left out of them.
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.