Transitions of Care Clinic (TOCC)

Not Applicable

Recruiting

• Conditions: Heart Failure With Preserved Ejection Fraction

• Registration Number: NCT06937827
• Lead Sponsor: Hackensack Meridian Health

Brief Summary

The transition period from hospital to home is a time of heightened risk for patients to experience adverse events, medication errors, and readmission to the hospital. Patients at the highest risk include older adults and patients with low health literacy, socioeconomic disadvantages, and/or multiple comorbidities. This project proposes to expand the existing Transitions of Care Clinic (TOCC) which was recently introduced in our institution in 2024, to bridge the gap in care between hospital discharge to home and connect discharged patients to their outpatient providers with a focus on patients with heart failure (HF).

The existing TOCC, a multidisciplinary team composed of a pharmacist and a nurse practitioner, seeks to improve the services that are currently being provided to patients and enhance the transitions of care process by providing patients with education, tools, and resources to help manage their chronic disease. With this study, we propose to expand TOCC by offering extensive education to patients via iPad videos and providing them with HF tool kits prior to their discharge. We will also assist with scheduling follow appointments with their outpatient providers and follow up with patients after the appointment takes place to re-evaluate their needs and reinforce self management of heart failure.

By targeting patients being treated for acute exacerbation of heart failure with preserved ejection fraction (HFpEF), this study aims to facilitate the transition of care, reduce hospital readmissions and improve patients' quality of life and satisfaction. Patients with HFpEF represent a majority of the HF patients that are readmitted at OUMC. HFpEF patients have fewer guideline recommended treatments and represent a vulnerable patient population. The HF tool kits will provide these patients with the essential tools, resources, and log sheets for self-management such as monitoring daily weights, monitoring blood pressure and heart rate. Patients provided with a kit will receive an initial phone call from TOCC within 1 to 3 days of discharge and a second phone call within 21-24-days post discharge.

Detailed Description

Not available

Study Timeline

• Study First Submitted: 2025-04-14
• Study First Submitted QC: 2025-04-14
• Study First Posted: 2025-04-22
• Study Start: 2025-06-26
• Status Verified: 2025-07
• Last Update Submitted: 2025-07-06
• Last Update Posted: 2025-07-08
• Primary Completion: 2026-12-15
• Study Completion: 2026-12-15

Recruitment & Eligibility

• Status: RECRUITING
• Sex: All
• Target Recruitment: 150

Inclusion Criteria

• Adults ages 18 to 90 years old discharged from Ocean University Medical Center (OUMC)
• Inpatient admission for heart failure with preserved ejection fraction (HFpEF) exacerbation
• Patient discharged home

Exclusion Criteria

• Refuse to participate in TOCC phone calls
• Discharged to a facility
• Discharged with homecare services
• Discharged on hospice services
• Hemodialysis
• Leave against medical advice (AMA)
• Pregnant
• Diagnosed with dementia
• Without medical capacity or unable to provide own consent

Study & Design

• Study Type: INTERVENTIONAL
• Study Design: PARALLEL

Primary Outcome Measures

Name	Time	Method
All-cause 30-day hospital readmission rate for heart failure	30 days post discharge	This measures the percentage of patients initially hospitalized for HF who are readmitted to the hospital for any reason within 30 days of discharge. This is a standard metric for evaluating HF care and aligns directly with the objective of reducing readmissions.

Secondary Outcome Measures

Name	Time	Method
Patient Satisfaction with Transition of Care	31 to 45 days post discharge	Patient-reported satisfaction with the transition of care process, measured using a post discharge survey.; Patient-reported satisfaction will be measured using a 5-item survey on patients' perception regarding the different components of the project (kit, education, phone calls and medication information). Four questions are using Likert scale 1-5 with 1 being "not helpful/satisfied" and 5 being very satisfied. The last question captures overall satisfaction with a Yes/No question.
7-Day Provider Follow-Up	7 day post discharge	Proportion of patients in each cohort (intervention and control) who receive a follow-up contact from an outpatient provider within 7 days of discharge.

Trial Locations

Locations (1)

Ocean University Medical Center; 🇺🇸 Brick, New Jersey, United States