A Technology-Assisted Care Transition Intervention for Veterans with Chronic Heart Failure or Chronic Obstructive Pulmonary Disease

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 DESCRIPTION (provided by applicant): The last decade has seen a steady increase in the resources that VHA uses to treat chronic heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD), both of which are among the most common reasons for admission and re-admission in VHA facilities. Multi-component care transition interventions can be effective, but are costly. One approach to reduce complexity and costs is to offload some work to technology. Informed by the sociotechnical model, this study proposes a technology-assisted care transition intervention founded on the concept of a virtual nurse that interacts with Veterans through different technology channels. The virtual nurse is an anthropomorphized computer program designed to simulate a discharge nurse. During the inpatient stay, the virtual nurse will appear on a computer touch screen and will educate Veterans with CHF or COPD about the important components of a care transition (drawing on the Coleman Care Transition Model) as well as how to send and receive text messages on their mobile phone. Following discharge to home, the virtual nurse will continue to coach Veterans and their family members and improve post-discharge access to care through two-way computer-tailored text messaging made possible by VHA's new HealtheDialog system. Our specific aims are to: 1. Refine methods and collect formative measures to guide implementation 2. Conduct an implementation trial of the technology-assisted care transition intervention 3. Evaluate the intervention, including its effectiveness, implementation, and budget impact. We propose a mixed methods formative assessment and simulation experiment to refine existing technologies to the VA care transition setting (Aim 1). This will be followed by a multi-site hybrid type 2 implementation trial (Aims 2 and 3) conducted at three purposefully-selected VHA facilities. The trial will evaluate the effectiveness of the virtual nurse intervention, and also evaluate a phased implementation protocol moving from centralized support (through a dedicated discharge assistant funded by the study) to facilitated distribution of the intervention (through nurse or nurse assistant members of clinical teams) into twelve clinical teams.