Background: Patients hospitalized with complex chronic conditions frequently experience preventable short- term readmissions due to inadequate transition support. Although structured discharge planning with telephone follow-up improves transition outcomes, these services often are unavailable, and proactive outreach is often inadequate once the patient returns home. Informal caregivers are invaluable for ensuring successful transitions, but many patients live alone, have an in-home caregiver who is struggling with competing demands, or live at a distance from adult children or other potential sources of support. New models are needed for transition support that include low-cost technologies and more structured assistance for patients'informal caregiving network, while providing patients'clinical teams with the information they need to avert health crises. Objectives: Consistent with AHRQ goals to improve transitions using accessible health IT, we will evaluate a novel intervention designed to improve the effectiveness of transition support for common chronic conditions via three mechanisms of action: (a) direct tailored communication to patients via regular automated calls post discharge, (b) support for informal caregivers within and outside of the patient's household via structured feedback about the patient's status and advice about how they can help, and (c) support for proactive care management including a web-based disease management tool, automated alerts about potential problems, and the capacity for asynchronous communication with patients and their caregivers. Specifically, the trial will determine: 1) whether the CarePartner intervention improves patients'readmission risk and functional status;2) the impact of the intervention on patients'self-care behaviors and the quality of the transition process;and 3) whether the intervention improves caregiver burden and stress levels. Methods: 380 older adults with complex chronic conditions will be identified upon admission to a university-based acute care medical service. Patients will be asked to identify up to 3 CarePartners (CPs);CPs will be spouses, adult children, and others in their social network willing to play an active role in their transition support. Patients will be randomized to the intervention or usual care. Intervention patients will receive automated assessment and behavior change calls, and their CPs will receive structured feedback and advice following each assessment. Patients'clinical team will have access to patients'assessment results via the web, will receive automated reports about urgent health problems, and will be able to communicate asynchronously with patients and CPs using a secure web page and a specially designed voicemail service. Patients will complete surveys at baseline, 30- and 90- days post discharge;utilization data will be obtained from hospital records. CPs and clinicians will be interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcomes will be 30 day readmission rates;secondary outcomes include functional status, self-care, and mortality risk.
We propose a randomized trial to evaluate the impact of a novel intervention designed to improve the effectiveness of support for transitions from hospital to home for patients with high- risk chronic conditions. The intervention has three hypothesized mechanisms of action: direct tailored communication to patients via regular automated calls post discharge;support for informal caregivers within and outside of the household via structured feedback about the patient's status and advice about how they can help;and support for proactive care management including a web-based disease management tool, automated alerts about potential problems, and the capacity for asynchronous communication with patients and their caregivers. The primary outcome will be 30-day readmission rates. Secondary outcomes include functional status, self-care, and mortality risk.