Project Details -

Ongoing

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.

A Patient-Facing App to Improve Care Transitions from Hospital to Home

Theme:

Engaging and Empowering Patients

Subtheme:

Using Digital Healthcare Tools in Chronic Disease Self-Management

A patient-facing app simplifying the information patients and caregivers receive has the potential to better engage patients and families in their healthcare post-discharge and reduce adverse events.

Care transitions from hospital to home can be a vulnerable time for patients

For hospitalized patients, the transition from the hospital back to their home is a vulnerable time. Complications, such as falls or medication errors, could lead to readmissions. This is especially true for older adults with multiple chronic conditions. These complications are caused by a variety of factors, including poor communication among the inpatient care teams, primary care teams, and patients and their families; poor quality and timeliness of discharge information; and poor patient understanding of care plans.

An app will provide support before and after discharge

Traditionally, hospital patients are given their post-discharge care plan instructions, the opportunity to ask questions, and a followup appointment with their primary care team when they are being discharged from the hospital. But no such transitional support or instruction is offered during the hospitalization or after discharge and prior to the followup appointment. Drs. Lipika Samal and Patricia Dykes from Brigham and Women’s Hospital wanted to know what would happen if patients and their families were provided more transition information during their hospitalization, as well as self-management reminders between discharge and their post-discharge followup appointment, and a summary of significant issues to share with their providers during the followup appointment.

To do this, the research team is developing a care transitions app for patients with multiple chronic diseases and their caregivers to better support the patient’s transition from hospital to home to primary care followup, and to reduce adverse events in the first 30 days after discharge. The app will facilitate pre-discharge conversations with providers, provide personalized falls-reduction information (e.g., based on their current medications), offer a digital post-discharge transitional care plan, deliver medication reminders and education, and allow for patients to submit questions and recovery goals before their post-discharge clinic visit. It will also prompt patients to report symptoms so providers can monitor their progress and provide support as needed.

"We want patients to use the app to start to have a conversation about discharge before it happens. If we wait until it's time to go, there's no time to do anything. And then once they get home, they'll get reminders for any medications that they're supposed to be taking. It also asks them to rate their symptoms, whether they're new or worse since their discharge. And then we tell them what to do if they have worsening symptoms.”- Dr. Patricia Dykes

A digital navigator will overcome the digital divide

One unique aspect of this intervention is that the team is introducing a digital navigator—a team member who will assess a patient’s digital literacy and provide appropriate training. Drs. Samal and Dykes hope that having a digital navigator work directly with patients will overcome challenges and hesitancy to use the app.

Ultimately, the goal of the research is to reduce post-discharge complications for high-risk patients. The team will study the app’s effectiveness, noting whether its use decreases falls, adverse medication events, and rehospitalizations, and whether it improves increased patient engagement and patient self-efficacy in managing their chronic diseases. If successful, the research team plans to share its knowledge and develop a toolkit to support widespread dissemination of the app.