A Longitudinal Telephone and Multiple Disease Management System to Improve Ambula

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DESCRIPTION (provided by the applicant): The aim of this study is to assess the effectiveness of Telephone-Linked Care for Complex Patients (TLC-C) in the care of patients with complex health care needs, defined as patients with multiple chronic diseases who have increased health-care utilization and other socio-economic vulnerabilities, frequently transitioning from inpatient to ambulatory care. The objective is to reduce preventable hospital utilization, improve quality of life, increase satisfaction with ambulatory care, improve disease-specific metrics, reduce net payer costs. TLC-C is a modification of an existing TLC-MD system that targets patients with multiple chronic diseases combined with a post-hospital discharge intervention (TLC-RED-Lit). TLC-C uses conversational computer telephony to monitor patients' multiple diseases between their ambulatory care visits. The system works in both routine (patient stable) and exacerbation (patient unstable) modes. The system monitors patients through "virtual visits" and detects and notifies clinicians about important clinical problems to attend to. It also promotes patient self-care (e.g., medication adherence and appointment preparation). Data collected through TLC-C are integrated into the patient's electronic health record (EHR). In emergent situations the system recommends going to the local ED. In urgent situations, an alert is sent to the clinician or to his/her coverage. Exacerbation mode is used when the patient is discharged from a hospital inpatient service or ED or has worsening symptoms. It concentrates on the exacerbating disease and monitors patient status (improved, stable, or deteriorating). Daily contact is maintained until the patient's status improves. Routine mode occurs with the patient at their baseline status and monitors the disease and the patients' self-care behaviors. A multi-method evaluation study of the patients, the providers, and the practice is proposed. This includes a two-arm randomized clinical trial of TLC-C versus usual care for patients with two or more chronic diseases, with at least one previous episode of acute hospital utilization over the last 12 months, being discharged from an urban hospital. The RCT will evaluate the system in 440 patients followed for 6 months. The primary outcome is acute hospital care utilization (unplanned hospitalizations and ED visits). Secondary outcomes include patient quality of life (EQ-5D), satisfaction (G-CAHPS), ambulatory appointment show rate and net payer costs. Disease-specific metrics (e.g., HbA1c or blood pressure) will be explored. Also to be performed are formative and summative qualitative studies of the implementation of the system, its use and performance over time, and its impact on the patients, providers, and the practice as a whole