Care Transitions App for Patients with Multiple Chronic Conditions

Care transitions are a vulnerable period for patients, leading to post-discharge adverse events, falls, medication errors, and readmissions. Specific challenges include poor communication among inpatient providers, patients, and the primary care team; poor quality and timeliness of discharge documentation; and suboptimal patient understanding of care plans. The goal of this research is to create an interoperable SMART-on-FHIR app for patients with multiple chronic conditions (MCCs) and evaluate its effectiveness through a cluster randomized trial. The care transitions app will bridge the transition between hospital, home, and primary care clinic to reduce adverse events in the first 30 days after discharge.

The specific aims of the project are as follows:

• Develop a care transitions app and a multi-component intervention.
• Pilot test the app and disseminate to inpatient and primary care settings.
• Evaluate the effectiveness of the app for patients over the age of 65 years with MCCs.

The Care Transitions App will incorporate components from the research team’s prior work, specifically falls-reduction content (e.g., personalized activity prescription). Using a participatory design process, the team will create the app to include: 1) a digital post-discharge transitional care pathway; 2) modules to help patients manage multiple chronic conditions (diabetes, congestive heart failure, or chronic kidney disease), including condition-specific post-discharge care plans with medication education; 3) a feature for patients to add recovery goals before their post-discharge clinic visit; and 4) an editable digital post-discharge report to be made accessible to the primary care team.

The team will pilot the app at Brigham and Women’s Hospital to iteratively refine the intervention before disseminating and piloting the app at Vanderbilt University Medical Center. This study will include usability testing and integration of the app into the sites' electronic health records using SMART-on-FHIR standards. The team will then evaluate the effectiveness of the app through a cluster-randomized trial enrolling patients over the age of 65 years with MCC including diabetes, congestive heart failure, or chronic kidney disease at BWH. Outcomes will include engagement of patients and families in their healthcare and the app’s role in the reduction in adverse events post-discharge. Collectively, lessons learned at both sites will inform a dissemination toolkit to support replication.