Improving Post-Hospitalization Transition Outcomes Through Accessible Health Information Technology and Caregiver Support: Protocol for a Randomized Controlled Trial

Objective: The goal of this trial is to evaluate a novel intervention designed to improve post-hospitalization support for older adults with chronic conditions via: direct tailored communication to patients using regular automated calls post discharge, support for informal caregivers outside of the patient's household via structured automated feedback about the patient's status plus advice about how caregivers can help, and support for care management including a web-based disease management tool and alerts about potential problems.

Methods: 846 older adults with common chronic conditions are being identified upon hospital admission. Patients are asked to identify a "CarePartner" (CP) living outside their household, i.e., an adult child or other social network member willing to play an active role in their post-discharge transition support. Patient-CP pairs are randomized to the intervention or usual care. Intervention patients receive automated assessment and behavior change calls, and their CPs receives structured feedback and advice via email and automated calls following each assessment. Clinical teams have access to assessment results via the web and receive automated reports about urgent health problems. Patients complete surveys at baseline, 30 days, and 90 days post discharge; utilization data is obtained from hospital records. CPs, other caregivers, and clinicians are interviewed to evaluate intervention effects on processes of self-care support, caregiver stress and communication, and the intervention's potential for broader implementation. The primary outcome is 30-day readmission rates; other outcomes measured at 30 days and 90 days include functional status, self-care behaviors, and mortality risk.

Conclusion: This trial uses accessible health technologies and coordinated communication among informal caregivers and clinicians to fill the growing gap between what discharged patients need and available resources. A unique feature of the intervention is the provision of transition support not only for patients but also for their informal caregivers.