Care Transitions App for Patients with Multiple Chronic Conditions

该项目的目标是创建一个可互操作的护理过渡应用程序（护理过渡应用程序）， 患有多种慢性病的患者，将在医院、家庭和 初级保健诊所，以减少出院后前30天内的不良事件。我们建议 开发一个护理过渡应用程序，该应用程序将在两个试验中心Brigham和 妇女医院和范德比尔特大学医疗中心，在住院和初级保健机构。的 Care Transitions应用程序将整合我们之前工作中的组件，特别是减少跌倒的内容。我们 建议创建三个新模块：1）数字化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/或慢性肾病），包括 特定条件的出院后护理计划，包括相关实验室值和药物教育，以及3）a 模块，供患者在出院后诊所之前输入他们的问题和他们自己的康复目标 访问该项目将包括可用性测试和集成的应用程序与史诗通过快速医疗保健 互操作性资源（FHIR）和SMART在布里格姆妇女医院（BWH）的FHIR技术 第一年。目标1：利用参与式设计开发Care Transitions App和多组件 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：试点 在BWH测试Care Transitions应用程序并传播给VUMC。2a.我们将试点测试护理过渡 在启动临床试验之前，应用并使用RE-AIM框架反复完善干预措施， 目标3（Y2）中的BWH。稍后，我们将在VUMC（Y 5）对Care Transitions App进行试点测试。2b.我们将传播 VUMC（Y 5）的Care Transitions应用程序，并使用RE-AIM框架来了解障碍和促进因素 在VUMC。在这两个地点吸取的经验教训将为传播工具包提供信息。目标3：评估 Care Transitions App通过一项随机分组试验招募了65岁以上的患者， MCC包括糖尿病、充血性心力衰竭和/或慢性肾病。我们将测试以下内容 假设：a. Care Transitions应用程序将与主要结局的减少相关， 出院后30天内发生出院不良事件（福尔斯、药物不良事件、其他不良事件）。B. Care Transitions应用程序将与次要结局的改善相关：30天再入院， 完成出院后电话联系，完成出院后初级保健门诊访视。C.的 Care Transitions应用程序将与改善以患者为中心的结局相关：全球健康、自我保健、 管理慢性病的有效性、自付成本、护理过渡措施3、患者体验。 结果：我们的团队将开发、评估和传播一种多成分干预措施，包括一种护理 全视线应用程序和数字导航培训旨在支持以下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.