{"type":"trials","record":{"id":31755,"source_id":"clinicaltrials-gov","external_id":"NCT04278794","title":"Optimizing Hospital-to-home Transitions for Older Adults With Stroke and Multimorbidity","brief_summary":"Stroke is the leading cause of death and adult disability in Canada. Sixty percent of these older adults (\\> 65 years) will return to their homes after a stroke and will require ongoing rehabilitation. About 92% of older adults have two or more chronic conditions. These patients often require services from a number of providers in a number of settings and are therefore, susceptible to fragmented health care when transitioning from hospital to home. New interventions are needed to improve the quality of care as patients move from hospital to home after a stroke. The proposed research project will examine the impact of a new intervention on patient/caregiver health, patient/caregiver and provider experience and costs, compared to usual health care services. The new intervention will be coordinated by a system navigator and consists of four core components: 1) development of a comprehensive discharge plan, 2) up to 6 home visits (supported by phone calls) by an interprofessional outpatient team, 3) monthly case conferences including the interprofessional care team who will discuss and focus on the patient's goals and care needs, and 4) linkages to other healthcare and community services. This multidisciplinary project will build on our previous study, which provided the groundwork for further study of this new intervention.","overall_status":"Completed","phases":[],"study_type":"INTERVENTIONAL","sponsor":"McMaster University","enrollment":90,"countries":["Canada"],"start_date":"2020-11-30","completion_date":"2022-12-05","last_update_date":"2023-03-23","source_url":"https://clinicaltrials.gov/study/NCT04278794","editorial_summary":"A registered study indexed because it matched monitored longevity research terms. Registry status: Completed. Registration does not establish safety or effectiveness.","first_seen_at":"2026-09-25T01:16:21.317971+00:00","last_seen_at":"2026-09-25T06:25:30.723+00:00","metadata":{"sex":"ALL","acronym":null,"age_range":"55 Years","comparator":"Control","organization":"McMaster University","interventions":["Transitional Care Stroke Intervention (TCSI)"],"registry_source":"ClinicalTrials.gov","outcome_measures":["Any hospital readmission for any cause within 6 months — 6-months","Change in health-related quality of life - mental health — Baseline; 6 months","Change in health-related quality of life - physical health — Baseline; 6 months","Change in self-efficacy — Baseline; 6 months","Change in depressive symptoms — Baseline; 6 months","Change in anxiety — Baseline; 6 months","Change in stroke physical function — Baseline; 6 months","Change in community integration — Baseline; 6 months","Change in use of health and social services — Baseline; 6 months","Change in caregiver strain — Baseline; 6 months","Relative risk of any hospital readmission for any cause within 6 months — Baseline; 6 months","Time to any hospital readmission for any cause within 6 months — Baseline; 6 months"],"design_description":"RANDOMIZED · PARALLEL · HEALTH SERVICES RESEARCH · DOUBLE","source_has_results":false},"controlled_terms":["Stroke","Transitional Care Stroke Intervention (TCSI)"],"relevance_confidence":80,"source_quality_score":100,"freshness_score":50,"publication_state":"published","match_explanation":"Title contains controlled term: multimorbidity.","quality_checked_at":"2026-09-25T06:25:35.871646+00:00","duplicate_cluster_key":"id:nct04278794","duplicate_of_id":null,"evidence_snapshot":{"status":"structured","version":1,"duration":"2020-11-30 to 2022-12-05","comparator":"Control","confidence":"structured-source","population":"ALL · 55 Years","provenance":{"duration":"start_date and completion_date","comparator":"registry arm fields","population":"registry eligibility fields","intervention":"registry intervention fields","participants":"enrollment","study_design":"study_type and registry design fields","evidence_stage":"phases","reported_outcome":"not available","outcomes_measured":"registry outcome-measure fields"},"generated_at":"2026-09-25T06:25:30.753Z","intervention":["Transitional Care Stroke Intervention (TCSI)"],"participants":90,"study_design":"RANDOMIZED · PARALLEL · HEALTH SERVICES RESEARCH · DOUBLE","subject_scope":"Human clinical study registration","evidence_stage":"Phase not reported","safety_context":"Eligibility, adverse-event details, and clinical decisions must be checked in the official registry and with qualified clinicians.","source_support":"Structured registry protocol metadata; no finding-level conclusion is generated.","main_limitation":"This is a study registration. No reusable structured result is available here, so it cannot show whether the intervention worked or was safe.","reported_outcome":null,"outcomes_measured":["Any hospital readmission for any cause within 6 months — 6-months","Change in health-related quality of life - mental health — Baseline; 6 months","Change in health-related quality of life - physical health — Baseline; 6 months","Change in self-efficacy — Baseline; 6 months","Change in depressive symptoms — Baseline; 6 months","Change in anxiety — Baseline; 6 months","Change in stroke physical function — Baseline; 6 months","Change in community integration — Baseline; 6 months","Change in use of health and social services — Baseline; 6 months","Change in caregiver strain — Baseline; 6 months","Relative risk of any hospital readmission for any cause within 6 months — Baseline; 6 months","Time to any hospital readmission for any cause within 6 months — Baseline; 6 months"],"regulatory_context":"Trial registration is not regulatory approval and does not establish that an intervention is available."},"clinical_trial_topics":[{"topic_slug":"multimorbidity","is_published":true,"match_reasons":["Title contains controlled term: multimorbidity.","Title supplies longevity context: older adult.","Study type is explicitly identified as INTERVENTIONAL."],"matched_fields":["title","title context","study type"],"relevance_score":80,"intelligence_topics":{"name":"Multimorbidity","slug":"multimorbidity"}}],"content_sources":{"name":"ClinicalTrials.gov","homepage_url":"https://clinicaltrials.gov/"}},"canonical_url":"https://www.immortal.life/trials/31755","automation_disclosure":"Generated automatically from cited source metadata. No scientist, clinician, researcher, editor, or human reviewer evaluates this publication before release."}