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Construct and test a whole-stage, timely, precise transitional care model with digital medicine and multi-level resources integration for the elderly with chronic disease

Construct and test a whole-stage, timely, precise transitional care model with digital medicine and multi-level resources integration for the elderly with chronic disease

Status
Active, not recruiting
Phases
Unknown
Study type
Interventional
Source
ChiCTR
Registry ID
ChiCTR2300069864
Enrollment
Unknown
Registered
2023-03-28
Start date
2023-08-06
Completion date
Unknown
Last updated
2023-08-07

For informational purposes only — not medical advice. Sourced from public registries and may not reflect the latest updates. Terms

Conditions

Chronic Heart Failure

Interventions

intervention group:Routine nursing, community management + transitional management intervention
control group:Routine nursing, community management

Sponsors

West China School of Nursing/West China Hospital, Sichuan University
Lead Sponsor

Eligibility

Sex/Gender
All
Age
60 Years to 100 Years

Inclusion criteria

Inclusion criteria: ?age 60 and older; ?diagnosis of chronic heart failure; ?residence in Chengdu city; ?return to home after discharge rather than other care facilities; ?ability to use cell phone WeChat; and ?voluntary participation in this study.

Exclusion criteria

Exclusion criteria: ?Patients with dementia; ?Patients with mental disorders; ?Patients with deafness; ?Patients with paralysis

Design outcomes

Primary

MeasureTime frame
Unplanned readmission rate within 30 days of patient discharge;

Secondary

MeasureTime frame
self-efficacy;self-management behavior;quality of life;social resource utilization;Transitional management satisfaction;Unplanned readmission rate within 90 days of discharge;

Countries

China

Contacts

Public ContactXiaolian Jiang

West China School of Nursing/West China Hospital, Sichuan University

jiangxiaolianhl@163.com+86 189 8060 1755

Outcome results

None listed

Source: ChiCTR (via WHO ICTRP) · Data processed: Feb 4, 2026