Transition Intervention for Frail Elderly

EnrollingByInvitation · 65+ · All Sexes · Baltimore, MD

Making Health Care Safer for Older Adults Receiving Skilled Home Health Care Services After Hospital Discharge

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About the trial for Frail Elderly

Eligible Conditions
Frail Elderly · Transitional Care · Home Health Care

Treatment Groups

This trial involves 2 different treatments. Transition Intervention is the primary treatment being studied. Participants will all receive the same treatment. There is no placebo group. The treatments being tested are not being studied for commercial purposes.

Main TreatmentA portion of participants receive this new treatment to see if it outperforms the control.
Transition Intervention
Control TreatmentAnother portion of participants receive the standard treatment to act as a baseline.


This trial is for patients born any sex aged 65 and older. There are 10 eligibility criteria to participate in this trial as listed below.

Inclusion & Exclusion Checklist
Mark “yes” if the following statements are true for you:
Aged ≥ 65 years
Is capable of assent
Hospitalized on a medical or surgical service
Referred for skilled home healthcare services (home health) after hospital discharge or skilled nursing facility (SNF) discharge
Family Caregivers
Assist the older adult with at least one healthcare task. Healthcare tasks include the following activities: managing health care bills, scheduling medical appointments, getting to and from medical appointments, getting medical equipment, getting services, getting information, following a diet, obtaining medication, planning a medication schedule, taking medication, and deciding to stop or change medication.
Home Health Providers
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Odds of Eligibility
Be sure to apply to 2-3 other trials, as you have a low likelihood of qualifying for this one.Apply To This Trial
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Approximate Timelines

Please note that timelines for treatment and screening will vary by patient
Screening: ~3 weeks
Treatment: varies
Reporting: Within 30 days after hospital discharge
This trial has approximate timelines as follows: 3 weeks for initial screening, variable treatment timelines, and reporting: Within 30 days after hospital discharge.
View detailed reporting requirements
Trial Expert
Connect with the researchersHop on a 15 minute call & ask questions about:
- What options you have available- The pros & cons of this trial
- Whether you're likely to qualify- What the enrollment process looks like

Measurement Requirements

This trial is evaluating whether Transition Intervention will improve 1 primary outcome and 2 secondary outcomes in patients with Frail Elderly. Measurement will happen over the course of Within 30 days after hospital discharge.

Mortality within 30 days of hospital discharge
Whether or not the older adult passes away within 30-days of hospital discharge.
ED visit use or re-hospitalization
Whether or not the older adult experiences an ED visit use or re-hospitalization within 30 days of hospital discharge. This is a composite endpoint.
Existence of Unresolved Medication Issues
Existence of any medication issues (incorrect medication list, incorrect prescription, unfilled prescription, etc.) within 30 days of hospital discharge.

Patient Q & A Section

Please Note: These questions and answers are submitted by anonymous patients, and have not been verified by our internal team.

What are common treatments for frail elderly?

Treatment options for the frail elderly depend on a number of factors, including level of function and capacity to manage their disease. Physicians should provide appropriate medical treatment tailored to individual patient needs.

Anonymous Patient Answer

Can frail elderly be cured?

With good multidisciplinary services, frail elderly have relatively low risk of mortality and hospitalization even when their functional status is severely compromised. Elderly can not be cured. They need long-term follow-up, and palliative care is recommended to reduce their quality of life for the best benefit to them and their family members.

Anonymous Patient Answer

What are the signs of frail elderly?

The FRAIL can help you screen for frail elderly patients at the hospital if you find them presenting with signs of frailty. Other symptoms such as weakness and exhaustion have been used as diagnostic criteria for frail elderly patients but they may not be exclusive.

Anonymous Patient Answer

How many people get frail elderly a year in the United States?

We estimated that about 13% of the population are frail elderly. For frail elderly women, the prevalence was 10% higher than that for frail elderly men. Our analysis was limited by the sample used and nonresponse rates were high.

Anonymous Patient Answer

What causes frail elderly?

The most important predictors of frailty, at the start of the study, could be the prevalence of major comorbidities. Older subjects should be identified and screened for frailty and comorbidities.

Anonymous Patient Answer

What is frail elderly?

Compared with non-frail elderly, frail elderly have a higher risk of mortality and poorer health-related quality of life. Despite different clinical and social characteristics, frail elderly still have to receive the same kind of care, like home care, as other elderly who do not suffer frailty.

Anonymous Patient Answer

Is transition intervention typically used in combination with any other treatments?

Transition interventions, such as transition planning, support and supervision, were frequently used in combination with health promotion, rehabilitation and medication. Future research could help us understand whether combined transition interventions and other treatments can influence the transition process.

Anonymous Patient Answer

Has transition intervention proven to be more effective than a placebo?

Transition intervention (TAU) is more effective in improving the quality of care transitions than a control (TAU+TC+TC). This result has implications for practice and policy implications for transitions of end-of-life care and for the effectiveness of medical transitions services including discharge planning.

Anonymous Patient Answer

Have there been any new discoveries for treating frail elderly?

It is difficult to ascertain whether the studies that were conducted on frail elderly showed positive or negative results. Future, well-designed and well-managed trials, aiming to understand the effectiveness of intervention strategies for treating frail elders with a variety of treatment strategies to prevent and treat specific illness conditions need to be conducted in large and well-controlled trials with the help of clinical psychologists and Geriatrics experts. The studies have also been conducted on the effectiveness of interventions specifically directed against the risk of falls in frail elders.

Anonymous Patient Answer

Have there been other clinical trials involving transition intervention?

This trial is a great opportunity to explore the impact of a structured transition intervention on outcomes of frail elderly patients admitted to a palliative care hospital.

Anonymous Patient Answer

Does frail elderly run in families?

No direct evidence of familial aggregation was found. Therefore, in this frail elderly population, there is no evidence to prove that a familial genetic predisposition and familial aggregation is associated.

Anonymous Patient Answer

How serious can frail elderly be?

Contrary to the common belief of some clinicians, a high percentage of frail patients are not at increased risk of deterioration, even when they are hospitalized with a number of comorbid conditions that are potentially fatal. Older, frail patients with multiple chronic diseases should not be excluded from research or medical treatment programs by the simple criteria of their age. The elderly are equally likely to benefit from care and research as young patients. In a large-scale prospective cohort study of older patients undergoing clinical research, the risk of death in frail elderly patients did not increase.

Anonymous Patient Answer
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