Living With Multimorbidity: Care Coordination and Symptom Management Program (COORDINATE)

Part of paid clinical trials in Baltimore, Maryland.

Sponsor
Johns Hopkins University
Study ID
NCT07157982
Status
Enrolling By Invitation

Conditions

  • Multimorbidity

Eligibility Criteria

Sex
ALL
Age
50 Years - N/A
Healthy Volunteers
Not accepted

Interventions

  • COORDINATE Program — BEHAVIORAL
    The COORDINATE Program is a nurse-led, multicomponent intervention designed to support older adults with multiple chronic conditions during their transition from hospital to home. The intervention is delivered over a 3-month period and includes the following components: 1. Discharge Planning Visit: Conducted in person or via video, this session includes a needs assessment and shared decision-making conversation to identify participants' values and preferences. 2. Question Prompt List: A tailored list of questions is provided to help participants engage more effectively with their care team. 3. Goal Setting: Participants work with a nurse to identify short-term goals and action steps related to their health and care needs. 4. Symptom Monitoring: Participants track symptoms weekly using a symptom checklist to support ongoing management and communication with providers.
  • Enhanced Usual Care — BEHAVIORAL
    Participants in this arm will receive enhanced usual care, which includes standard discharge instructions, scheduled check-ins, and a resource toolkit with educational materials. The content includes guidance on symptom management, advance care planning, and available community resources. Participants will receive follow-up reminders and wellness checks but will not receive the structured, nurse-led intervention provided in the COORDINATE Program.

Study Details

The goal of this clinical trial is to learn if a new care program, called the COORDINATE Program, can help older adults with two or more chronic health conditions. These individuals are being discharged from special hospital units called Intermediate Care Units (IMCUs), which care for people who are very sick but don't need intensive care. The main questions this study wants to answer are: 1. Can the COORDINATE Program improve participants' quality of life? 2. Can the program reduce emergency visits, intensive care admissions, and rehospitalizations? Researchers will compare the COORDINATE Program to the enhanced usual care with extra support to see if it works better. Participants will receive either the COORDINATE Program or enhanced usual care. They will also complete surveys at three different time points: before starting the intervention, at 3 months, and at 12 months. For those in the COORDINATE Program group, a trained nurse will guide them through: 1. A needs assessment to find out what matters most to them 2. A list of helpful questions to ask their care team 3. Goal-setting to support managing their conditions 4. Tracking their symptoms and progress 5. Attend a discharge visit and have 5 follow-up phone or video calls over 3 months Participants in both groups will be compensated for completing the surveys. The study hopes to improve how care is given to older adults with complex health needs and reduce unnecessary hospital visits.

Key Dates

Start date
May 31, 2026
Status verified
May 2026
Primary completion
Sep 30, 2027
Completion
Mar 31, 2028

Study Design

Enrollment
10 participants (estimated)
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE

Arms

  • Experimental: COORDINATE Program Intervention
    Participants receive the nurse-led COORDINATE Program, a nurse-led structured intervention focused on transitional care, including a discharge planning visit (pre-discharge and/or within 48 hours of discharge) and follow-ups at 1 week, 4 weeks, 6 weeks, and 3 months.
  • Other: Enhanced Usual Care
    Participants receive enhanced usual care, including standard discharge teaching, a multimorbidity management toolkit, and follow-up check-ins.

Primary Outcome Measure

Change from Baseline in Health-related Quality of Life as Measured by the EuroQoL at 3 months [ Time Frame: Baseline and 3 months post-discharge ]

Locations (1)

FacilityCityStateZIPSite coordinators
Johns Hopkins Health SystemBaltimoreMaryland21205-

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