For complex medical patients, the transition from hospital to home-based care is a vulnerable period, placing the patient at high risk for adverse events, including the experience of a medical error or loss of community tenure. Recent successful studies have used a Care Transition Intervention (CTI), using a nurse who conducts home visits, telephone follow-up, and who provides assistance at and after discharge. Although successful, this model is costly and is not feasible in settings serving geographically dispersed populations. We propose a cost-efficient technological solution to the problems presented by the traditional CTI through """"""""e-Coach,"""""""" an Interactive-Voice-Response-supported (IVR) Care Transition coaching intervention. We propose to develop and evaluate """"""""e-Coach,"""""""" by performing a randomized controlled trial of this intervention versus a usual care comparison group. To our knowledge, a conceptually grounded IVR-supported care transition intervention has not, to date, been rigorously tested.
Our Specific Aims are to: 1) Randomize 720 patients at high risk of transition-related errors (complex adult patients discharged alive after a hospitalization with congestive heart failure (CHF) or chronic obstructive pulmonary (COPD) disease from a geographically diverse area including many rural areas across Alabama and the South) to an IVR-supported care transition program (""""""""e-Coach"""""""") versus a usual care comparison group. The IVR system will actively call patients at multiple (daily for first 4 weeks) intervals after discharge. In a stepped-care approach, the IVR will be further supported by a Care Transition nurse who monitors patient symptoms through the e-Coach IVR and supports patient self management through telephone-based interactions when needed, up to 2 months after discharge;2) Evaluate use of the e-Coach by patients and healthcare providers;3) Evaluate the impact of the e-Coach on patient outcomes, including 90 day re-hospitalizations, successful community tenure over a 3 month period, medication discrepancies, and patient self-efficacy based on the previously validated Care Transition Measure;and 4) Quantify the cost associated with the e-Coach. If e-Coach is successful, it is likely to be easily disseminated and could result in substantial avoidance of medical errors in the hospital-to-home transition period along with notable reductions in the risks and costs of re-hospitalizations.
For complex medical patients, the transition from hospital to home-based care is a vulnerable period, placing the patient at high risk for adverse events. Using a Care Transition conceptual model, we propose developing and evaluating, through a randomized controlled trial, e-Coach, an Interactive-Voice-Response-supported (IVR) Care Transition coaching intervention, focused initially on patients hospitalized with heart failure or obstructive lung disease. If this intervention is successful, it is likely to be easily disseminated and could result in substantial avoidance of medical errors in the hospital-to-home transition period along with notable reductions in the risks and costs of rehospitalizations.
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