Transitional Care Model Evaluation 2020

  • End date
    Jun 25, 2024
  • participants needed
  • sponsor
    Mathematica Policy Research, Inc.
Updated on 25 January 2021
heart failure
chronic obstructive pulmonary disease
copd exacerbation


The study is a randomized controlled trial to estimate the effects of the transitional care model (TCM) on hospital admissions and patients' experience during the year following the patient's qualifying discharge. The University of Pennsylvania, where TCM was developed, will be the coordinating center for the implementation. The study will be conducted in four large health systems spread throughout the U.S., drawing patients from 9 hospitals in those systems. Eligible patients are older adults (age 65 and older) admitted to a participating hospital with symptoms of heart failure (HF), chronic obstructive pulmonary disease (COPD), or pneumonia (PNA). The evaluation will be conducted by Mathematica.


The Transitional Care Model (TCM) is an advanced practice registered nurse (APRN) led, team-based, care management strategy designed to improve the care and outcomes of high-risk older adults transitioning from hospital to home. Eligible patients who agree to participate in the study will be randomly assigned to either the intervention group, which receives the TCM intervention, or the control group, which receives usual care (standard hospital discharge planning and post-hospital follow up services). The target sample size for the study is 1600, evenly divided into intervention and control groups, with 400 patients recruited from each of the 4 partnering health systems (Swedish, Trinity Health, University of California, San Francisco, and Veterans Health Administration (VHA) - St Louis and Cleveland). Data will be collected at intake, prior to randomization, by enrollment coordinators at each of the participating hospitals. Followup data will be collected in a survey of patients conducted 90 days after discharge, and from claims data obtained from Medicare, Medicare Advantage plans, and the VHA.

Condition Pulmonary Disease, Lung Disease, Chronic Obstructive Lung Disease, COPD (Chronic Obstructive Pulmonary Disease), Chronic Obstructive Lung Disease, Heart failure, Congestive Heart Failure, Heart failure, Upper respiratory infection, Throat and Tonsil Infections, Pneumonia, Pneumonia, Pneumonia (Pediatric), Throat and Tonsil Infections, COPD (Chronic Obstructive Pulmonary Disease), Reactive Airway Disease, Pneumonia (Pediatric), Congestive Heart Failure, Lung Disease, chronic obstructive pulmonary disease, pneumoniae, pneumonitis, lung inflammation, COPD, chronic obstructive pulmonary disease (copd)
Treatment Usual Care, Transitional care model (TCM)
Clinical Study IdentifierNCT04212962
SponsorMathematica Policy Research, Inc.
Last Modified on25 January 2021


Yes No Not Sure

Inclusion Criteria

Age 65 years and older
Admitted from home with Pneumonia OR with a history of HF or COPD with symptoms of HF or COPD exacerbation or whose symptoms suggest a new HF or COPD diagnosis
English and non-English speaking, able to respond to questions
Reachable by telephone after discharge
Resides within the geographic service area
Consent to participation

Exclusion Criteria

Enrolled in Medicare's Hospice or End-Stage Renal Disease programs
Presence of active and untreated psychiatric conditions (ICD10: F10-F29)
Long-term care resident
Undergoing active cancer treatment
Currently enrolled in another RCT
Clear my responses

How to participate?

Step 1 Connect with a study center
What happens next?
  • You can expect the study team to contact you via email or phone in the next few days.
  • Sign up as volunteer  to help accelerate the development of new treatments and to get notified about similar trials.

You are contacting

Investigator Avatar

Primary Contact


Additional screening procedures may be conducted by the study team before you can be confirmed eligible to participate.

Learn more

If you are confirmed eligible after full screening, you will be required to understand and sign the informed consent if you decide to enroll in the study. Once enrolled you may be asked to make scheduled visits over a period of time.

Learn more

Complete your scheduled study participation activities and then you are done. You may receive summary of study results if provided by the sponsor.

Learn more

Similar trials to consider


Browse trials for

Not finding what you're looking for?

Every year hundreds of thousands of volunteers step forward to participate in research. Sign up as a volunteer and receive email notifications when clinical trials are posted in the medical category of interest to you.

Sign up as volunteer

user name

Added by • 



Reply by • Private

Lorem ipsum dolor sit amet consectetur, adipisicing elit. Ipsa vel nobis alias. Quae eveniet velit voluptate quo doloribus maxime et dicta in sequi, corporis quod. Ea, dolor eius? Dolore, vel!

  The passcode will expire in None.

No annotations made yet

Add a private note
  • abc Select a piece of text from the left.
  • Add notes visible only to you.
  • Send it to people through a passcode protected link.
Add a private note