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RECRUITING Not applicable ClinicalTrials.gov

Care Coordination and Passive Mobile Data Monitoring to Improve Mental Health Care

Sponsor: VA Office of Research and Development • ClinicalTrials.gov ID: NCT07549178

Registry updated: 2026-08-19
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Description

Providing care to individuals with serious mental illness can be challenging, requiring ongoing monitoring, treatment adjustments, and coordination of various medical and social services. Rates of emergency service and hospital use are high due to unexpected social, medical, and mental health crises. Stressors and poor adherence with treatment are common and can lead to rapid worsening in symptoms, job loss, homelessness, incarceration, or suicide. Clinician visits can be infrequent. Patient-clinician contact between visits is challenging and often nonexistent. As such, illness exacerbations usually occur with no clinician awareness in real time, leaving limited opportunity to provide services. Clinicians need interventions that are capable of monitoring and quickly detecting worsening behaviors and illness, to improve care coordination, outreach, and treatment. This project studies the effectiveness of enhanced care coordination using passive mobile data monitoring and support from peer specialists, with the goal of improving outcomes and reducing the need for acute care.

Interventions

  • Care Coordination Mobile (Behavioral)
    Mobile monitoring, peer coaching, and enhanced care coordination

Eligibility criteria

Inclusion Criteria: * a medical record diagnosis of Serious Mental Illness (SMI) * defined as schizophrenia, schizoaffective disorder, or bipolar disorder * receipt of care at the VA site during the prior 9 months * a Care Assessment Need (CAN) score over the 75th percentile, indicating high risk for hospitalization or death in the upcoming year * ownership of a smart phone Exclusion Criteria: * none

Conditions

Severe Mental Illness

Locations

  • VA Greater Los Angeles Healthcare System, West Los Angeles, CA — West Los Angeles, California, United States
  • Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA — Philadelphia, Pennsylvania, United States
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Official Source

Data sourced from ClinicalTrials.gov, a service of the U.S. National Institutes of Health.

View Official Record