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

Sponsor: Wake Forest University Health Sciences • ClinicalTrials.gov ID: NCT07661355

Registry updated: 2026-09-21

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Description

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 study also involves families in education and provides families skills-building experiences that can help with caregiving stress, problem-solving, and communicating with the healthcare team. The approach will help the family member prepare for their loved one's transition home and provide coaching with the goal of reducing the mental, physical and financial burden of providing care at home. To spread the intervention across many states, the study team will be using telephone calls, video calls, and other technologies as families prefer.

Interventions

Patient-Centered Program (Other)
Effective strategies focused on the patient such as patient needs assessment, multi-disciplinary discharge planning, discharge instructions, follow-up education, and follow-up assessments.
Family Caregiver Enhanced Program (Other)
Caregiver strategies such as a family caregiver needs assessment, structured education, and skill building.

Eligibility criteria

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)

Conditions

Care Transition

Locations

Davie Medical Center — Bermuda Run, North Carolina, United States
High Point Medical Center — High Point, North Carolina, United States
Atrium Health Wake Forest Baptist Wilkes Medical Center — North Wilkesboro, North Carolina, United States
Atrium Health Wake Forest Baptist Medical Center — Winston-Salem, North Carolina, United States

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Official Source

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

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