Tele-transitions of Care (TTOC). A 12-month, Randomized Controlled Trial evaluating the use of Telehealth to achieve Triple Aim Objectives

Abstract

Background : Poor transitions of care leads to increased health costs, over-utilization of emergency room departments, increased re-hospitalizations and causes poor patient experiences and outcomes. This study evaluated Telehealth feasibility in improving transitions of care. Methods : This is a 12-month randomized controlled trial, evaluating the use of telehealth (remote patient monitoring and video visits) versus standard transitions of care with the primary outcomes of hospital readmission and emergency department utilization and secondary outcomes of access to care, medication management and adherence and patient engagement. Electronic Medical Record data, Health Information Exchange data and phone survey data was collected. Multi-variable logistic regression models were created to evaluate the effect of Telehealth on hospital readmission, emergency department utilization, medication adherence. Chi-square tests or Fisher’s exact tests were used to compare the percentages of categorical variables between the Telehealth and control groups. T tests or Wilcoxon rank sum tests were used to compared means and medians between the two randomized groups. Results : The study conducted between June 2017 and 2018, included 102 patients. Compared with the standard of care, Telehealth patients were more likely to have medicine reconciliation (p = 0.013) and were 7 times more likely to adhere to medication than the control group (p = 0.03). Telehealth patients exhibited enthusiasm (p = 0.0001), and confidence that Telehealth could improve their healthcare (p= 0.0001). Telehealth showed no statistical significance on emergency department utilization (p = 0.691) nor for readmissions (p = 0.31). 100% of Telehealth patients found the intervention to be valuable, 98% if given the opportunity, reported they would continue using telehealth to manage their healthcare needs, and 94% reported that the remote patient monitoring technology was useful. Conclusions: Telehealth can improve transitions of care after hospital discharge improving patient engagement and adherence to medications. Although this study was unable to show the effect of Telehealth on reduced healthcare utilization, more research needs to be done in order to understand the true impact of Telehealth on preventing avoidable hospital readmission and emergency department visits.

Perceived Self-Efficacy, Confidence, and Skill Among Factors of Adult Patient Participation in Transitional Care: A Systematic Review of Quantitative Studies

“…Schmaderer et al (2016) determined lower patient activation scores were associated with higher levels of acute care utilization, while Coleman et al (2004) and Chen et al (2018) determined person-centered transition planning across settings resulted in lower levels of acute utilization in the time period following discharge. Like Noel et al (2020), Bull et al (2000) did not find a statistically significant ○ Self-report Noel et al (2020) difference in patient participation efforts and post-discharge utilization, but did identify lower readmissions. Kvale et al (2016) examined utilization through a primary care follow-up lens and determined higher patient activation levels did not increase the likelihood of attendance, though did identify statistically significant lower perceptions of care involvement for myocardial infarction patients that completed cardiac rehabilitation post-discharge.…”

“…Studies also ranged in disciplinary perspective. Six of the studies were conducted by nursing (Bull et al, 2000;Chen et al, 2018;Jangland et al, 2012;Lenaghan, 2019;Schmaderer et al, 2016;Ulin et al, 2016), followed by four by medicine (Coleman et al, 2004;Epstein-Lubow et al, 2014;Kvale et al, 2016;Noel et al, 2020) and the remaining two were implemented by occupational and physical therapy (Arnetz et al, 2010;Smith & Fields, 2020). The theoretical framework differed between studies.…”

“…The theoretical framework differed between studies. The four studies contributed by the discipline of medicine were grounded in a medical transitional care perspective known as the Care-transition Initiative (CTI) (Coleman et al, 2004;Epstein-Lubow et al, 2014;Kvale et al, 2016;Noel et al, 2020). This conceptual framework, derived from patient and caregiver feedback of factors considered most valuable during times of care-transition, is composed of four transitional care pillars designed to mitigate quality and safety care-transition risks and support active and independent participation in care-transitions.…”

“…The majority of studies examining interventions intended to partner the healthcare professional and patient in a mutual, agreed-upon goal setting and coaching session, were implemented by nurses and limited to the predischarge time period (Bull et al, 2000;Chen et al, 2018;Coleman et al, 2004;Jangland et al, 2012;Lenaghan, 2019). Coleman et al (2004), Lenaghan (2019) and Chen et al (2018) implemented programs that expanded care settings and two programs were solely focused on the time period following hospital discharge with interventions delivered by physicians and occupational and physical therapists (Noel et al, 2020;Smith & Fields, 2020). Finally, the study by Kvale et al (2016) was conducted in the ambulatory setting by a Master's degree-prepared mental health professional.…”

“…Patient and healthcare team partnerships in individualized transition planning led to higher perceived health, satisfaction with planning, and a greater feeling of preparedness. Ulin et al (2016) determined early discharge planning and communication between the hospital and community healthcare team members resulted in shorter hospital stays, while Noel et al (2020) found statistically significant greater medication adherence and positive feedback for those participatory in a telehealth care-transitions program. In the study by Arnetz et al (2010), an inverse relationship between patient ratings of planning inclusion and goal achievement was identified.…”