A Technology Assisted Care Transition Intervention for Veterans With CHF or COPD

Not Recruiting

Trial ID: NCT02632552


Transition from hospital to home places patients in jeopardy of adverse events and increases their risk for rehospitalization. CHF is the most prevalent chronic condition among U.S. adults and COPD is the third leading cause of death in the U.S. Both CHF and COPD represent significant burdens for the VHA healthcare system. Care transitions can be supported through multi-component interventions, but are costly to implement. Virtual nurses provide an effective medium for explaining health concepts to patients, and previous work indicates patients find virtual nurses acceptable. The investigators will implement and evaluate a virtual nurse intervention to provide automated, tailored, and timely support to Veterans transitioning from hospital to home. As effective care transition interventions incorporate both inpatient and outpatient components, the virtual nurse will first engage with patient onscreen during their inpatient stay and then via text message post-discharge. This project has the potential to improve the care transition experience for patients, caregivers and healthcare providers.

Official Title

A Technology-Assisted Care Transition Intervention for Veterans With Chronic Heart Failure or Chronic Obstructive Pulmonary Disease

Stanford Investigator(s)

Paul Heidenreich, MD

Professor of Medicine (Cardiovascular)


Inclusion Criteria:

* Veterans
* Diagnosis of chronic heart failure or chronic obstructive pulmonary disease
* Admission to a general medical service
* Able and willing to engage with touchscreen technology
* Have a text-enabled cellular phone to receive the post-discharge text messages

Exclusion Criteria:

* Not Veterans
* Not diagnosed of chronic heart failure or chronic obstructive pulmonary disease
* Not admitted to a general medical service
* Not capable of using touchscreen technology
* Do not have a text-enabled cellular phone


behavioral: Technology-assisted care transition intervention

behavioral: Active attention control

Not Recruiting

Contact Information

Stanford University
School of Medicine
300 Pasteur Drive
Stanford, CA 94305
Paul Heidenreich, MD