Madison, Wisconsin 53792


The goal of the project is to conduct a prospective, randomized-controlled clinical trial to determine the extent to which the Coordinated-Transitional Care (C-TraC) program impacts transitional care quality, patient cognition/function, caregiver stress and 30-day rehospitalizations in patients with documented diagnoses of dementia discharged from the hospital to the community.

Study summary:

Patients with dementia often experience poor quality transitions from the hospital to the community. In response, the investigators developed and piloted the Coordinated-Transitional Care (C-TraC) program--a low-cost, telephone-based intervention designed to improve care coordination and outcomes in hospitalized patients with dementia or other high-risk conditions discharged to community settings. A single-blind, prospective, randomized-controlled trial will be used with participants being randomly assigned to receive usual (i.e. standard) care, or usual care plus the C-TraC intervention. Outcomes will be assessed via scheduled phone-calls at 14, 30, and 90 days post-hospitalization. A 45-day phone call will also be conducted to complete a brief satisfaction survey with the caregiver about their post-hospital experience.


Patient Inclusion Criteria: - English-speaking - Have a working telephone - Hospitalized on medical inpatient wards at UWHC - A documented pre-hospitalization diagnosis of dementia. - Alzheimer's Disease Cooperative Study - Clinical Dementia Rating (ADCS-CDR) score of > 0 - Have a family member/informal caregiver who has regular contact with them in the community setting Caregiver Inclusion Criteria: - English-speaking - Have a working telephone - Have contact with patient a minimum of once per week Patient Exclusion Criteria: - Discharged to institutional settings - No identified caregiver - Discharged to hospice - Followed by complex case management or any form of intensive case management (e.g. transplant, congestive heart failure, dialysis) - Score moderate-high on modified ASSIST tool for alcohol



Primary Contact:

Principal Investigator
Amy J Kind, MD, PhD
University of Wisconsin - Madison, School of Medicine and Public Health, Department of Medicine

Amy J Kind, MD, PhD
Phone: (608) 280-7000

Backup Contact:


Location Contact:

Madison, Wisconsin 53792
United States

There is no listed contact information for this specific location.

Site Status: Recruiting

Data Source:

Date Processed: January 21, 2020

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