Tele-Transitions of Care: An Approach to Reduce 30-Day Readmission Using Tele-Health Technology; a Randomized Controlled Trial Study Protocol

Abstract

Introduction: Avoidable hospital readmissions and medical errors are costly and dangerous. Many hospital systems have invested in various transitions of care models, health information systems and now increasingly, in telehealth, to help improve care after hospitalization. Although many models and strategies exist to improve care transitions, very few guidelines address the role of health technology, data analytics and health information exchanges within this process. Few studies have described an optimal workflow for physicians performing virtual clinical surveillance using telehealth. Furthermore, although many published studies have conducted telehealth transition of care interventions for patients with specific disease pathologies, few studies evaluate interventions using multi-modal remote patient monitoring for patients with mixed-chronic conditions. This appears to be an ideal target audience for telehealth interventions given that, the factors affecting patient risks for readmission are often complex and multifactorial. Our study aims to evaluate a new workflow for addressing comprehensive transition of care, using risk stratification, telehealth remote patient monitoring, and patient-centered virtual visits. We also introduce a new communication tool for relaying tele-communication. Aim: To describe current study protocol and demonstrate the steps and stakeholders involved to ensure proper integration and scalability to other practices.