NCT07661355 · RECRUITING
Comparing Two Acute Care Transition Programs for Older Adults and Their Family Caregivers
This study compares two programs that help older adults get from hospital to home. One focuses on the patient only. The other adds coaching and support for the family caregiver. Researchers are measuring safe time at home, fewer ER visits and readmissions, and daily activities. It is not a drug trial, and no phase applies.
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)
The sponsor's own eligibility wording, lightly reformatted. The study team makes the final eligibility decision — worth discussing with your doctor.
Eligibility criteria as of 2026-09-21