Research & Program Areas

The CarePartner Program: Transitions from Hospital to Home

Older hospitalized adults frequently experience preventable readmissions. In this study funded by the National Institute on Aging, CMCD investigators are evaluating a novel intervention designed to improve the effectiveness of transition support for older adults with common chronic conditions via three mechanisms of action: (a) direct tailored communication to patients via regular automated calls post discharge, (b) support for informal caregivers living outside of the patient’s household via structured feedback about the patient’s status and advice about how they can help, and (c) support for proactive care management including a web-based disease management tool, automated alerts about potential problems, and the capacity for asynchronous communication with patients and their caregivers.

The trial will determine whether the CarePartner intervention improves patients’ readmission risk and functional status; the impact of the intervention on patients’ self-care behaviors and the quality of the transition process; and whether the intervention improves caregiver burden and stress levels.

Learn more about the CarePartner Program.

For more information, contact Jenny Chen at


Interactive Voice Response (IVR), Mobile Health, Multiple Chronic Conditions, U-M Health System

Return to Research and Program Areas