Care Transitions App for Patients with Multiple Chronic Conditions

该项目的目标是创建可互操作的关怀过渡应用程序(关怀过渡应用程序)，用于 患有多种慢性疾病的患者将在医院、家庭和 初级保健门诊，以减少出院后前30天的不良事件。我们建议 开发一款护理过渡应用程序，该应用程序将在Brigham和Brigham两个试验站点吸引患者和护理人员 妇女医院和范德比尔特大学医疗中心，在住院和初级保健环境中。这个 关爱过渡应用程序将纳入我们之前工作的组件，特别是减少跌倒的内容。我们 建议创建三个新模块：1)数字出院后过渡护理计划；2)多个模块 慢性疾病(MCC：糖尿病、充血性心力衰竭和/或慢性肾脏疾病)，包括 具体情况的出院后护理计划，包括相关的实验室价值和药物教育，以及3)a) 用于患者在出院后诊所前输入他们的问题和他们自己的康复目标的模块 参观。该项目将包括可用性测试和通过FAST Healthcare将应用程序与EPIC集成 布里格姆妇女医院(BWH)的互操作性资源(FHIR)和智能FHIR技术 第1年.目标1：利用参与式设计开发护理过渡应用程序和一个多组件 干预，包括由数字导航器提供的基于人员和基于任务的干预。目标2：飞行员 在BWH测试关怀过渡应用程序，并传播给VUMC。2A。我们将对关怀过渡进行试点测试 APP并使用RE-AIM框架在启动临床试验之前反复改进干预措施，网址为 目标3(Y2)中的BWH。稍后，我们将在VUMC试运行关怀过渡应用程序(Y5)。2B。我们将传播 VUMC(年第5年)的关怀过渡应用程序，并使用RE-AIM框架了解障碍和促进者 在VUMC。在这两个地点吸取的经验教训将成为一个传播工具包。目标3：评估 护理过渡应用程序通过一项整群随机试验招募65岁以上的患者 MCC包括糖尿病、充血性心力衰竭和/或慢性肾脏疾病。我们将测试以下内容 假设：a.护理过渡应用程序将与主要结局的减少相关，在- 出院后30天内出院不良事件(跌倒、药物不良事件、其他不良事件)。B. 护理过渡应用程序将与二次结局的改善相关：30天的重新住院， 完成出院后电话呼叫，完成出院后初级保健门诊就诊。C. 护理过渡应用程序将与以患者为中心的结果的改善相关：全球健康、自我 管理慢性病的有效性，自付费用，护理过渡措施3，患者体验。 结果：我们的团队将开发、评估和传播包括护理在内的多成分干预 过渡应用程序和数字导航器培训旨在支持患有以下疾病的患者的安全护理过渡 多种慢性病和支持广泛传播的工具包。

The goal of this project is to create an interoperable care transitions application (Care Transitions App) for patients with multiple chronic conditions that will bridge the care transition between hospital, home, and primary care clinic in order to reduce adverse events in the first 30 days after discharge. We propose to develop a Care Transitions App which will engage patients and caregivers at the two trial sites, Brigham and Women’s Hospital and Vanderbilt University Medical Center, in both inpatient and primary care settings. The Care Transitions App will incorporate components from our prior work, specifically falls-reduction content. We propose to create three new modules: 1) a digital post-discharge transitional care plan, 2) modules for multiple chronic conditions (MCC: diabetes, congestive heart failure, and/or chronic kidney disease), including condition-specific post-discharge care plans with relevant lab values and medication education, and 3) a module for patients to enter their questions and their own goals for recovery prior to the post-discharge clinic visit. This project will include usability testing and integration of the application with Epic via the fast healthcare interoperability resources (FHIR) and SMART on FHIR technology at Brigham and Women’s Hospital (BWH) in Year 1. Aim 1: Utilize participatory design to develop the Care Transitions App and a multi-component intervention, including person-based and task-based interventions delivered by a Digital Navigator. Aim 2: Pilot test the Care Transitions App at BWH and disseminate to VUMC. 2a. We will pilot test the Care Transitions App and use the RE-AIM framework to iteratively refine the intervention before launching the clinical trial at BWH in Aim 3 (Y2). Later, we will pilot test the Care Transitions App at VUMC (Y5). 2b. We will disseminate the Care Transitions App at VUMC (Y5) and use the RE-AIM framework to understand barriers and facilitators at VUMC. Lessons learned at both sites will inform a dissemination toolkit. Aim 3: Evaluate the effectiveness of the Care Transitions App through a cluster randomized trial enrolling patients over the age of 65 years old with MCC including diabetes, congestive heart failure, and/or chronic kidney disease. We will test the following hypotheses: a. The Care Transitions App will be associated with a decrease in the primary outcome, post- discharge adverse events (falls, adverse drug events, other adverse events) within 30 days of discharge. b. The Care Transitions App will be associated with improvements in secondary outcomes: 30-day readmissions, completion of post-discharge phone calls, and completion of post-discharge primary care clinic visits. c. The Care Transitions App will be associated with improvements in patient-centered outcomes: global health, self- efficacy for managing chronic conditions, out of pocket costs, Care Transitions Measure 3, patient experience. Outcome: Our team will develop, evaluate, and disseminate a multicomponent intervention including a Care Transitions App and Digital Navigator training aimed at supporting safe care transitions for patients with multiple chronic conditions and a toolkit to support widespread dissemination.