IVR-Enhanced Care Transition Support for Complex Patients
| Status: | Archived |
|---|---|
| Conditions: | Chronic Obstructive Pulmonary Disease, Cardiology, Pulmonary |
| Therapuetic Areas: | Cardiology / Vascular Diseases, Pulmonary / Respiratory Diseases |
| Healthy: | No |
| Age Range: | Any |
| Updated: | 7/1/2011 |
| Start Date: | February 2010 |
E-Coaching: IVR-Enhanced Care Transition Support for Complex Patients
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, the investigators 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. This trial will test the primary hypothesis that the
proportion of patients with one or more re-hospitalizations during a 90-day post-discharge
follow-up period will be less in an IVRsupported care transition intervention (e-Coach)
compared to a "usual care" comparison group.
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 provides assistance at and after discharge. Although successful, this model
is costly and and 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. 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 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 3 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 rehospitalizations, 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.
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