A Clinician-Patient Dual Behavior Change Framework to Leverage Informed Digital Nudges to Reduce Hospital Readmissions and Improve Patient Outcomes: A Trial for Scalable Strategy to Reduce Readmissions (PREVENT-R)

NCT07890961 | Not Yet Recruiting

• 2 other identifiers: 20000436025P30AG024968-24
• Study Type: interventional
• Target: 800
• Locations: 1 country
• Sites: 1

Brief Summary

The PREVENT-R trial will evaluate an intervention targeting both clinician and patient behavior. The clinician-focused piece consists of an electronic medical record-based digital nudge presented to emergency department clinicians caring for eligible older adults at high risk of readmission. The nudge is intended to prompt clinicians to consider referral to the Service Navigator Program from the Agency on Aging of South Central Connecticut for patients with needs that may be addressed through community-based services and supports. The study will evaluate whether these mechanisms (clinician referral and patient program acceptance behavior) are associated with subsequent Emergency Department (ED) revisits and 30-day hospital re-admissions.

Conditions

Readmission; Readmission Rates; Readmission, Hospital; Elderly (People Aged 65 or More)

Keywords

Digital Health

Outcome Measures

Primary Outcomes (1)

• Percentage of participants with hospital readmissions

  Hospital readmission within 30 days of the index ED visit.

  30 days following the index ED

Secondary Outcomes (5)

• Percentage of participants referred to the SNP

  up to 3 months

• Percentage of participants that accept or decline SNP services

  up to 3 months

• Post-SNP assessment

  up to 3 months

• Percentage of participants that interact with SNs

  up to 3 months

• Percentage of participants that utilize services

  up to 3 months

Study Arms (2)

EMR-based digital nudge

EXPERIMENTAL

The EMR will generate a digital nudge prompting the ED clinician to consider referral of the eligible patient to the SNP. Patients referred to the SNP will have the opportunity to engage with an SN and receive individualized navigation and support based on their identified needs.

Behavioral: Digital nudge prompting

Control Arm

NO INTERVENTION

No study-related EMR digital nudge will be generated. Clinicians will proceed with usual ED care and discharge practices, which may include referral to the SNP when clinically appropriate.

Interventions

Digital nudge prompting BEHAVIORAL

The EMR will generate a digital nudge prompting the treating ED clinician to consider referral of the patient to the SNP.

EMR-based digital nudge

Eligibility Criteria

• Age: 65 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Older Adult (65+)

You may qualify if:

• Patient Participants:
• Hospitalization within the previous 30 days.
• Identified as being at high risk for readmission by the EMR-embedded algorithm.
• Reside in a geographic area identified as having high health-related social needs based on the Community Health Needs Assessment (CHNA).
• For consent-dependent patient research activities, able to provide informed consent.
• Clinician Participants:
• ED clinicians who have experience with the PREVENT-R intervention and/or SNP referral process and are able to provide informed consent for participation in the qualitative interview.
• Service Navigator Participants:
• Individuals involved in delivering SNP services to patients enrolled in or referred through PREVENT-R and who are able to provide informed consent for participation in the qualitative interview.

You may not qualify if:

• Patient Participants:
• Require immediate hospital admission.
• Receiving hospice, skilled nursing facility, or palliative care.
• Unable to participate in study procedures in English or Spanish.

Sponsors & Collaborators

• Yale University: lead
• National Institute on Aging (NIA): collaborator

Study Sites (1)

Yale New Haven Hospital System

New Haven, Connecticut, 06520, United States

Location

Study Officials

• Fuad Abujarad, PhD, MSc

  Yale University

  PRINCIPAL INVESTIGATOR

Central Study Contacts

Fuad Abujarad, PhD, MSc

CONTACT

203-737-5088; fuad.abujarad@yale.edu

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: NONE
• Purpose: PREVENTION
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: SPONSOR

Model Details: Adults aged 65 years and older presenting to the YNHH ED at the York Street and Saint Raphael Campus locations who have had a hospitalization within the previous 30 days and are identified by an EMR-embedded algorithm as being at high risk for readmission.

Study Record Dates

• First Submitted: October 15, 2026
• First Posted: October 23, 2026
• Study Start (Estimated): November 1, 2026
• Primary Completion (Estimated): May 1, 2028
• Study Completion (Estimated): November 1, 2028
• Last Updated: October 23, 2026

Record last verified: 2026-10

Data Sharing

• IPD Sharing: Will not share

Locations

US (1)