Background: The time between hospitalization and the first ambulatory visit is a transition that has a high risk for medical errors. We have developed the """"""""Re-Engineered Hospital Discharge"""""""" (RED);ten mutually reinforcing components that are delivered using a tool called the """"""""After Hospital Care Plan"""""""" (AHCP). Using a nurse to deliver the RED, we have shown that the RED (1) improves self perceived readiness for discharge;(2) decreases adverse events;and (3) lowers hospital utilizations at 90 days, especially for patients with limited health literacy. The RED is now accepted as a National Quality Forum """"""""Safe Practice"""""""". As there is a need to deliver the RED at a lower cost, we created a Virtual Patient Advocate (or VPA), a computerized animated character who utilizes best practices from provider-patient communication theory to emulate the face-to-face conversational behavior of an empathic provider - emphasizing nonverbal communicative behavior such as gaze, posture, and gestures. The VPA uses the AHCP to prepare patients for discharge and determines their degree of understanding of self-care, medications, and follow-up. Goal: To expand the use of the VPA to interact with patients during the transition from the hospital to the ambulatory setting - and in the ambulatory setting - to improve the delivery, monitoring, and updating of patient-centered information to ensure patients have the information they need to make health care decisions. Methods: We propose to deliver the VPA intervention to medically underserved patients in an urban safety net hospital. After adapting the technologies and tools for use in the ambulatory setting, we will (1) link the system to hospital ambulatory IT systems;(2) pre-test it with potential users and clinicians;and (3) enroll subjects on high-risk medication regimens who will be instructed to (a) """"""""check in"""""""" daily with a hand held version of the VPA in the days following hospitalization - the VPA will offer health education, monitoring and advice on self-care and medication use, and assess the patient's understanding and adherence;(b) interact with the VPA on a kiosk in the doctor's office immediately before the first ambulatory visit to produce a report about adherence and any unresolved questions or concerns that will be presented to the physician;and (c) again meet the VPA after the ambulatory visit to be instructed on the contents of the Ambulatory Care Plan and any changes in the medication regimen that have been made during the office visit. Concurrently, we will begin the dissemination by introducing this intervention into Celebration Health hospital in Florida, a member of a national test bed. Outcome Measures: Evaluation will include assessment of: (1) patient and provider satisfaction;(2) patient knowledge of self-care and medications;(3) study attrition;(4) fidelity of exposure;(5) the therapeutic alliance between the patient and the VPA;(6) patient activation, or the ability to identify and voice specific concerns at the ambulatory visit;and (7) adverse events after the ambulatory visit. A national consultant will evaluate the dissemination at the test bed hospital. The time between hospitalization and the first ambulatory visit is a transition that has a high risk for medical errors. We have developed the """"""""Re-Engineered Hospital Discharge"""""""" (RED), including ten mutually reinforcing components, that has shown to be effective and is accepted as a National Quality Forum """"""""Safe Practice"""""""". This project will create a Virtual Patient Advocate, a computerized animated character that emulates the face-to face conversational behavior of an empathic provider and interacts with patients during the transition from the hospital to the ambulatory setting to improve the delivery, monitoring, and updating of patient-centered information to ensure patients have the information they need to make health care decisions.
