New Care Pathways for Supporting TRANSitional CARE From Hospital to Home Using AI and Personalized Digital Assistance
For patients and families
In plain language
An automatic summary of structured registry data. It is an orientation aid, not a substitute for the official protocol or a physician assessment.
- What is being studied
- The protocol lists: TRANSCARE Digital Remote Monitoring Ecosystem.
- Who it may be relevant to
- Registry conditions: Transitional Care, Remote Patient Monitoring (RPM), Geriatric Multimorbidity. Basic parameters: from 65 years · All.
- What needs checking
- Age, condition and sex are only basic indicators. Prior treatment, laboratory values and other mandatory requirements appear in the eligibility criteria below.
- Where it takes place
- Italy, Norway, Romania
- Next step
- Save the trial, show it to the treating physician, and confirm current recruitment with the study center. Costs, documents and travel →
Unsure about the terms? Read our patient guide →
Overview
The objective of the TRANSCARE study is to evaluate the use of a digital remote monitoring system to reduce the risk of 30-day readmission in multimorbid elderly patients. The pilot study is multicenter, and the trial will be conducted across 3 sites: Italy, Romania, and Norway. The overall goal of the TRANSCARE project is to create a digital monitoring ecosystem capable of identifying and preventing the risk of readmission. Two hundred and ten older adults aged over 65, who meet the inclusion and exclusion criteria, will be enrolled in the study. They will be randomized into two groups and allocated to an intervention group or a control group.
Interventions
- Other TRANSCARE Digital Remote Monitoring Ecosystem
A digital remote monitoring suite comprising connected home medical devices for physiological parameter measurement, a wearable activity tracker, and an integrated telemonitoring software platform designed for patient self-management and clinical risk detection.
Primary outcome measures
- 30-Day Re-hospitalization Rate [Time frame: 30 days post-discharge]
Secondary outcome measures (6)
- Re-hospitalization Rate at 60 days [Time frame: 60 days post-discharge]
- Re-hospitalization Rate at 90 Days [Time frame: 90 days post-discharge]
- Change in Physical Performance [Time frame: Baseline, 30 days, 60 days, and 90 days post-discharge.]
- Platform Usability [Time frame: 30 days, 60 days, and 90 days post-discharge]
- Psychosocial Impact of Technology [Time frame: 30 days, 60 days, and 90 days post-discharge]
- Change in Digital Health Literacy [Time frame: Baseline and 90 days post-discharge]
Eligibility criteria
Inclusion criteria
- Able to stand and walk even with support;
- Mini Mental State Examination (MMSE) ≥ 18;
- Clinical Frailty Scale (CFS) score 2-7;
Exclusion criteria
- Allergy to nichel components;
- Concomitant participation in other studies;
- Severe dementia condition
- Mild to moderate dementia condition in the absence of the caregiver
- Terminal chronic renal failure with the need for dialysis
- Inability or unwillingness to sign written informed consent;
- Pacemaker or implantable cardioverter defibrillator;
- Metastatic cancer or immunosuppressive therapy;
- Significant visual or hearing impairment;
- Severe systemic diseases with life expectancy < 6 year;
- Move to nursing home after discharge
Criteria are shown verbatim from the registry (in English). Final eligibility is always assessed by the study center.
Healthy volunteers: No
Study design
- Allocation
- Randomized
- Model
- Parallel assignment
- Masking
- Open label
- Primary purpose
- Health services research
Study locations
Italy · 1 center
- IRCCS INRCA Hospital — Ancona
Norway · 1 center
- Farsund Kommune — Farsund
Romania · 1 center
- Institutul Inimii "Niculae Stăncioiu" — Cluj-Napoca
Identifiers
NCT: NCT07731126 · INRCA_004_2026 · THCS-1449