e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients

For patients with complex medical conditions, the transition from hospital to home-based care is a vulnerable period during which the patient is at high risk for adverse events including medical errors. The Care Transition Intervention (CTI) was developed to address this problem. CTI utilizes a nurse to conduct home visits, telephone followup, and provide assistance at and after discharge with medication self-management, maintenance of a personal health record, timely followup with primary or specialty care, and identification of "red flags" indicative of a worsening condition. Studies examining the CTI report that it is a successful program. However, it is costly and not feasible in settings serving geographically dispersed populations.

Dr. Ritchie and her team developed a cost-efficient technological solution based on the CTI: an interactive voice response (IVR)-supported care transition coaching intervention, e-Coach, that supports medical patients with complex conditions as they transition from hospital to home-based care. The e-Coach, using the TeleSage software application, supports patients through medication self-management assistance, maintenance of a paper-based personal health record, timely followup with primary or specialty care, and the creation of red flags. Patient red flags were identified in the IVR system when patients noted problems with medications, inability to obtain a followup appointment, worsening symptoms, or confusion about their personal health record. The care transition nurses called patients with red flags and helped them with their problems. The e-Coach has a Web-delivered monitoring dashboard that displays meaningful data for the care transition coach to use to monitor patient status, listen to patient messages, and record responses.

In this project, the intervention was evaluated through a randomized controlled trial involving patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) who were discharged from a large tertiary hospital. Rehospitalization rates at 30 days, days in the community, and costs for patients randomized to the intervention and those randomized to usual care were compared.

There was no difference in the primary outcomes for CHF, but intervention patients with COPD had significantly fewer days in the hospital at 30 days and had lower rehospitalization rates. In addition, the team found that use of the intervention was high and that many red flags were identified in both the CHF and COPD patients. For the first call, 63 percent of the intervention patients had one or more red flags, suggesting a real need for post-discharge care and followup.