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Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers

RecruitingNAAges 18 Years - anyAllWake Forest University Health Sciences
NCT07661355 on ClinicalTrials.gov ↗
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In plain words

What the trial is, and whether it could suit you

This study investigates better ways to help people after they leave the hospital and how to involve their families in this process. The main goal is to see if adding family support to a patient-centered hospital-to-home intervention helps patients stay safely at home, spend fewer days back in the emergency room or going back into the hospital. The study team also wants to see if the family-centered approach helps improve the patient's ability to do everyday activities without feeling overwhelmed. Two approaches are being compared: one focuses just on the patient, and the other includes special strategies to better support families involved too. Family will be involved in assessing what the patient and family needs. The family-focused approach not only emphasizes the experience, health, and safety of the patient but also the experience of the family member caring for the older adult. The

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📋 Eligibility rules (as published)
Patient Inclusion Criteria: * 65 and older * English and Spanish speaking * Preadmission location: community dwelling * Distance from Hospital: Local and Distant (rural) included * Cognitive impairment, dementia allowed * Technology Literacy: Flexible from high to low * EPIC readmission risk score over 12 * Discharged home Patient Exclusion Criteria: * Admitted from skilled nursing facility * Discharged to skilled nursing facility * Left Against Medical Advice (AMA) * Planned readmission * Died during index admission * Caregiver unwilling to participate * Admitted to surgical services Caregiver Inclusion Criteria: * Adults 18 and older * English and Spanish speaking * Providing tangible support to patient * Distance from Hospital: Local and Distant (rural) included * Only Mild Cognitive Impairment allowed * Able to be trained in Video Visit Technology * Available to support post-discharge Caregiver Exclusion Criteria: • Has a greater than a mild cognitive impairment (\< 12 on MoCA)
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What it tests

  • Patient-Centered Program
  • Family Caregiver Enhanced Program
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Where

4 sites
Davie Medical Center
Bermuda Run, United States
High Point Medical Center
High Point, United States
Atrium Health Wake Forest Baptist Wilkes Medical Center
North Wilkesboro, United States
Atrium Health Wake Forest Baptist Medical Center
Winston-Salem, United States
🤝 Taking part is your choice, and you can leave at any time. Only the trial team can confirm you are eligible — always decide together with your own doctor.
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