This study is trying to improve the hospital-to-home transition for people with heart failure who receive home care services. The study will test an intervention called I-TRANSFER-HF, which differs from usual care by combining early home health nurse visits and outpatient medical appointments. The study is interested in two questions: 1. Is I-TRANSFER-HF better than usual care at preventing heart failure patients from returning to the hospital within 30 days? 2. Are there parts of I-TRANSFER-HF that are easy or hard to implement in the real world? The researchers will answer these questions by testing the intervention among pairs of hospitals and home health agencies across the country. During the study, the hospital-agency pairs will be asked to implement I-TRANSFER-HF. The researchers will then compare the results from before and after I-TRANSFER-HF was adopted. They will also interview people from these hospitals and agencies to see how I-TRANSFER-HF is being implemented under real-world conditions.
Age range
18 Years
Sex
ALL
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AI-rewrites the medical criteria so a patient or caregiver can understand them. Always confirm with the trial site.
Bring these to your next appointment. They're a starting point for a shared conversation — not a sign you qualify or a recommendation to enrol.
Generated to help you prepare — always confirm anything about your own eligibility and care with the study team and your doctor.
The trial coordinator is the person who runs the study day to day. These cover the practical side — logistics, costs, and what taking part would actually mean for your life. The study team confirms whether you meet the criteria; these are questions to ask, not a sign you qualify.
A starting point for the conversation — always confirm anything about your own eligibility, costs, and care with the study team and your doctor.
All-cause 30-day hospital readmission
Timeframe: 30 days following post-Index HF Hospitalization
Number of Eligible patients
Timeframe: 12 months
Number of Eligible Patients Who Received Protocol Components
Timeframe: 12 months
Modality of outpatient follow-up
Timeframe: 12 months
Timeliness of Post-Hospital Discharge Home Health Nursing Evaluation
Timeframe: 12 months
Timeliness of Post-Hospital Outpatient Follow-Up
Timeframe: 12 months
Feasibility of implementing I-TRANSFER-HF (Qualitative Interviews)
Timeframe: 30 days after intervention (year of intervention)
Feasibility of implementing I-TRANSFER-HF (Surveys)
Timeframe: 30 days after intervention (year of intervention)