Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions (Massachusetts)

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The transition from inpatient to outpatient settings is a vulnerable time for patients and stressful for caregivers: new treatments have been initiated, conditions require close monitoring, and the plan of care is in flux. Approximately 19 to 23 percent of hospitalized patients experience preventable adverse events after discharge, many that are due to suboptimal monitoring of medical conditions, medication errors and nonadherence, and failure to execute the care plan. Achieving a high-quality transition requires effective understanding of the discharge plan by patients and caregivers as well as seamless communication with key inpatient providers to address patients’ concerns during and immediately after hospitalization. Use of patient portals in the acute care setting is a promising strategy to engage patients and caregivers during hospitalization; but their use in this setting is new.

This project will implement and evaluate a previously developed, interactive, patient-centered discharge toolkit (PDTK). The toolkit consists of three components: a predischarge checklist tool; the Patient Safety Dashboard, which includes a discharge preparedness status indicator; and the capability for real-time messaging between patient and provider. Patients and caregivers can access the toolkit from an acute care patient portal during the transition from the hospital to the ambulatory setting.

The specific aims of this project are as follows:

  • To refine and implement an interactive PDTK on a general medicine unit that patient and caregivers can use to prepare for discharge and communicate with key providers during the transition home 
  • To conduct a pilot study to evaluate the effect of the PDTK on patient activation 
  • To identify barriers and facilitators of implementation, adoption, and use of the PDTK by patients, caregivers, and providers using qualitative and quantitative methods 

The project team will utilize mixed-methods to evaluate the toolkit. It is anticipated that the PDTK will improve patient activation at discharge and favorably impact patient-reported, self-efficacy with regard to participating in, understanding, and executing the discharge plan; postdischarge resource utilization; and perception of patient-provider communication compared to usual care.

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