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Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF)
Improving TRansitions ANd OutcomeS for Heart FailurE Patients in Home Health CaRe (I-TRANSFER-HF): A Type 1 Hybrid Effectiveness- Implementation Trial
Who can join
Ages 18 and older · All sexes · Healthy volunteers welcome
Full eligibility criteria
Aim 1, Inclusion Criteria: * Adults hospitalized for HF who transition from participating hospitals to their partner HHC agency during the study period. Aim 1, Exclusion Criteria: * Patients hospitalized for HF and discharged: home without HHC, or to an inpatient rehabilitation facility, skilled nursing facility, or hospice; patients with end stage renal disease on dialysis and those with left ventricular devices. Aim 2, Inclusion Criteria: \- Healthcare professional involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads. Aim 2, Exclusion Criteria: \- Healthcare professional not involved in the transition of heart failure patients from the acute care setting (hospital) to HHC (home health care) agencies, and the implementation of the I-TRANSFER-HF at one of the four participating hospital-HHC dyads.
About the study
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.
What is being tested
- I-TRANSFER-HF (other)
Sponsor: Weill Medical College of Cornell University · Participants: 1,094 · Started: Jul 28, 2026
Contact the study team
- Madeline R Sterling, MD, MPH, MS · Phone: 6469625029
Official record on ClinicalTrials.gov — NCT06118983
Locations in the U.S.
| New York | VNS Health Partners in Care, New York Weill Cornell Medicine, New York |
Conditions
From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.