University of Chicago
Transitions of Care (TOC) between hospital, ambulatory, and home settings for high-risk, frequently hospitalized adults with chronic diseases, such as chronic obstructive pulmonary disease (COPD) are complex, costly, and vulnerable to safety threats and poor health outcomes. One potential solution to address this gap in care is the Transitional Care Model (TCM), which utilizes a patient-centered approach with in-home interventions; since in-person in-home visits are costly, using innovative telehealth, such as virtual visits via teleconferencing may be just as effective with greater feasibility, scalability, and sustainability, particularly in the post-COVID-19 era as has been seen the rapid expansion of these technologies. With a transdisciplinary team of experts from cognitive science, care transitions/handoffs, human factors engineering, design, implementation science, and health services research, the study team proposes to implement and evaluate via a randomized clinical trial the "TELE-TOC: Telehealth Education: Leveraging Electronic Transitions Of Care for COPD patients," intervention which includes a virtual visit, pharmacy-based, in-home intervention for COPD patients to improve medication use and patient outcomes among a population at high risk for readmission and medication safety events.
Transitions of Care (TOC) for high-risk, frequently hospitalized adults with chronic diseases are complex, costly, and vulnerable to safety threats and poor health outcomes. Communication breakdowns, information lapses, and IT-induced unintended consequences can result in poor follow-up and medication non-adherence, both of which contribute to preventable readmissions or emergency room (ER) visits. The Transitional Care Model (TCM) aims to reduce such risks through a holistic, collaborative, patient-centered approach with in-home interventions. Prior to the coronavirus disease 2019 (COVID-19)…
Inclusion Criteria: * Adults 18 years or older * Admitted to the hospital on a general inpatient ward with a COPD Exacerbation * Enrolled/seen by our COPD Hospital Readmission Reduction Program Exclusion Criteria: * Patients younger than 18 years of age
Patients will have their medications reviewed by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)
Patients will be provided with inhaler education by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)
Patients will receive a COPD consult by an advanced practice nurse as part of standard of care
Patients will have their medications reviewed by member(s) of the clinical care team as part of standard of care
Patients will receive a post-discharge nurse 48 hour phone follow-up call as part of standard of care
Patients will be scheduled for a 1-2 week post-discharge visit with the COPD advanced practice nurse as part of standard of care