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

Summary

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.

Conditions

• Multimorbidity

Interventions

BEHAVIORAL

COORDINATE Program

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.

BEHAVIORAL

Enhanced Usual Care

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.

Sponsors & Collaborators

• Johns Hopkins University

  lead OTHER

Principal Investigators

• Binu Koirala, PhD, MGS · Johns Hopkins School of Nursing

Study Design

Allocation

RANDOMIZED

Purpose

SUPPORTIVE_CARE

Masking

DOUBLE

Model

PARALLEL

Eligibility

Min Age

50 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2026-05-31

Primary Completion

2027-09-30

Completion

2028-03-31

Countries

• United States

Study Locations