New Care Pathways for Supporting TRANSitional CARE From Hospital to Home Using AI and Personalized Digital Assistance

NCT07731126 · tracked via the Priya Life Science Italy tracker

Sponsor

Istituto Nazionale di Ricovero e Cura per Anziani

Phase

Not applicable

Started

2025-12-12

Last updated

2026-07-28

Condition(s) studied

Transitional CareRemote Patient Monitoring (RPM)Geriatric Multimorbidity

Investigational drug(s) / intervention(s)

TRANSCARE Digital Remote Monitoring Ecosystem

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.

Study summary

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.

Eligibility

Sex

ALL

Min age

65 Years

Max age

—

Healthy volunteers

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

Primary outcome measure(s)

30-Day Re-hospitalization Rate — 30 days post-discharge
Percentage of participants re-admitted to the hospital for any all-cause unplanned readmission within 30 days following discharge.

Trial sites (3)

Facility	City	Region	Status
IRCCS INRCA Hospital	Ancona	Italy	Recruiting
Farsund Kommune	Farsund	Norway	Recruiting
Institutul Inimii "Niculae Stăncioiu"	Cluj-Napoca	Romania	Recruiting

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Official registry record

This page summarises publicly available registry data for informational purposes — not medical advice. Eligibility is determined by each study team; patients should discuss participation with their clinician.

View NCT07731126 on ClinicalTrials.gov ↗ ← All trials in Italy