A Technology Assisted Care Transition Intervention for Veterans With CHF or COPD

Trial ID or NCT#



not recruiting iconNOT RECRUITING


Transition from hospital to home places patients in jeopardy of adverse events and increases their risk for rehospitalization. CHF is the most prevalent chronic condition among U.S. adults and COPD is the third leading cause of death in the U.S. Both CHF and COPD represent significant burdens for the VHA healthcare system. Care transitions can be supported through multi-component interventions, but are costly to implement. Virtual nurses provide an effective medium for explaining health concepts to patients, and previous work indicates patients find virtual nurses acceptable. The investigators will implement and evaluate a virtual nurse intervention to provide automated, tailored, and timely support to Veterans transitioning from hospital to home. As effective care transition interventions incorporate both inpatient and outpatient components, the virtual nurse will first engage with patient onscreen during their inpatient stay and then via text message post-discharge. This project has the potential to improve the care transition experience for patients, caregivers and healthcare providers.

Official Title

A Technology-Assisted Care Transition Intervention for Veterans With Chronic Heart Failure or Chronic Obstructive Pulmonary Disease

Eligibility Criteria

Ages Eligible for Study: Older than 18 Years
Sexes Eligible for Study: All
Accepts Healthy Volunteers: No
Inclusion Criteria:
  1. - Veterans - Diagnosis of chronic heart failure or chronic obstructive pulmonary disease - Admission to a general medical service - Able and willing to engage with touchscreen technology - Have a text-enabled cellular phone to receive the post-discharge text messages
Exclusion Criteria:
  1. - Not Veterans - Not diagnosed of chronic heart failure or chronic obstructive pulmonary disease - Not admitted to a general medical service - Not capable of using touchscreen technology - Do not have a text-enabled cellular phone


Paul Heidenreich, MD
Professor of Medicine (Cardiovascular)

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Paul Heidenreich, MD