Transitions of care (TOC) for high-risk, frequently hospitalized adults with chronic conditions are complex and costly and can expose vulnerable patients to higher risk of complications. Communication breakdowns, information lapses, and unstructured discharges can result in poor followup and medication nonadherence, both of which contribute to preventable readmissions or emergency department visits. The Transitional Care Model (TCM) aims to reduce such risks through a holistic, collaborative, patient-centered approach with in-home interventions, but is costly, and in the wake of public health emergencies—such as the COVID-19 pandemic—is not always feasible. One potential feasible, sustainable, and scalable solution is to use telehealth for in-home virtual visits; however, use of telehealth for post-discharge TOC interventions has not been routinely implemented.

For patients with chronic obstructive pulmonary disease (COPD), medication adherence and inhaler education post-hospitalization is imperative to reduce the misuse of prescriptions leading to rehospitalization. Many individuals with COPD experience high rates of acute care visits after initial hospitalization, which contribute to unnecessary healthcare costs. These significant impacts have driven the development of Medicare’s Hospital Readmission Reduction Program (HRRP), aimed to incentivize hospitals to implement TOC programs for improved COPD care. However, currently the HRRP program is not meeting full expectations to meet the needs of patients who are continuing to misuse their inhalers.

In-home interventions as part of the TCM could potentially improve medication skills and outcomes for patients with COPD. Evidence on inhaler misuse shows the need for inhaler education reinforcement after hospital discharge; telehealth solutions may be valuable to address this. The research team from the University of Chicago will implement and evaluate “TELE-TOC: Telehealth Education: Leveraging Electronic Transitions Of Care for COPD Patients.” This in-home intervention will use telehealth to conduct virtual visits with members of our pharmacy team.

The specific aims of the research are as follows:

• Iteratively design, develop, and test evidence-based virtual pharmacist visits to address medication use, skills training, and self-management needs for patients with COPD, using user-centered design methods.
• Implement and evaluate the TELE-TOC intervention compared to ambulatory visits for patients with COPD enrolled in the existing COPD TOC program, using a type II hybrid effectiveness implementation randomized controlled trial (RCT).
• Develop a dissemination strategy for nationwide dissemination of TELETOC for other COPD TOC programs.

The researchers will design the telehealth program using stakeholder input, including feedback in participatory design sessions and prototyping demonstrations with patients and families enrolled in the HRRP, clinicians, and telehealth experts. To determine the effectiveness of the TELE-TOC program, the research team will conduct a RCT to compare our usual care approach which is a TOC program that relies on in-person visits in the hospital and clinic with TELE-TOC + usual care that will additionally include at-home virtual sessions with members of our pharmacy team. Outcomes studied include the change in inhaler technique among patients, the number in acute care visits, usability and adoption rate of technology, and sustainability of virtual versus in-person visits.

The research team anticipates that the virtual visits with our pharmacy team will be an accessible option for patients and will result in improved medication use and outcomes among COPD patients at high risk for readmission. If proven to be successful, the team will develop a dissemination strategy and roadmap with national stakeholders for a nationwide adoption of the TELE-TOC program.