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

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.

NCT Number	NCT07731126
Lead Sponsor	Istituto Nazionale di Ricovero e Cura per Anziani Collaborators: Technical University of Cluj-Napoca, Romania, INSTITUTUL INIMII "NICOLAE STANCIOIU" CLUJ-NAPOCA, Romania, Tellu AS, Norway, Farsund Kommune, Norway, Karde AS, Norway
Conditions	Transitional Care, Remote Patient Monitoring (RPM), Geriatric Multimorbidity
Enrollment	210 participants
Start Date	2025-12-12
Primary Completion	2027-02-28 (estimated)
Study Completion	2027-02-28 (estimated)
Updated on ClinicalTrials.gov	2026-07-28