Eligibility Module
The Eligibility Module contains detailed information about who can participate in the clinical trial. This includes eligibility criteria, age restrictions, gender requirements, healthy volunteer status, and study population descriptions, helping researchers understand who is eligible to participate in the study.
Eligibility Module path is as follows:
Study -> Protocol Section -> Eligibility Module
Eligibility Module
Ignite Creation Date:
2025-12-25 @ 4:14 AM
Ignite Modification Date:
2025-12-25 @ 4:14 AM
NCT ID:
NCT04224220
Eligibility Criteria:
Inclusion Criteria:
* Discharged from the hospital in the past 7 days
* LACE+ score of 59 or greater and at least two chronic conditions
* Index hospitalization with discharge directly to community dwelling home (home, assisted living)
* English speaking
* Normal cognitive function - mild dementia or mild cognitive impairment is allowed if a caregiver is able to work with the care coordinator and patient during program enrollment
* Mayo Clinic or Mayo Clinic Health System provider managing the patient's care (e.g. primary care); patient is assigned to the panel of a Mayo Clinic Medical Doctor/Nurse Practitioner/Physician Assistant
* Access to and ability to communicate via telephone (either patient or caregiver)
Exclusion Criteria:
* Psychiatric hospital admission
* Patients with a serious and persistent mental health disorder or severe treatment interfering behavior that require a higher level of service than is available at the patient's clinic
* Untreated active substance or alcohol abuse
* Dementia or moderate to severe cognitive impairment
* Discharged to one of the following: rehabilitation unit, skilled nursing facility, assisted living memory unit, group home
* Pregnancy
* Active treatment for cancer
* Receiving dialysis or transplant services
* Life expectancy \< 6 months or enrolled in hospice or palliative care programs
* Patient is unwilling to sign a Release of Information (ROI); ROI allows those providing care, internal and external, to be actively involved in the patient's care coordination
* Patients with active tuberculosis (TB)
* Violent patient flag noted in Epic (for adult medical care coordination)
* Patient declines home visit (for adult medical care coordination)
* Patient is already enrolled in remote patient monitoring or the care transitions program
Healthy Volunteers:
False
Sex:
ALL
Minimum Age:
18 Years
Study:
NCT04224220
Study Brief:
Protocol Section:
NCT04224220