The 7-Visit Transition of Care Hospital to Home Intervention: A Pilot Study

The long-term objective of this study is to inform and enhance the ability of UAB Hospitalist Medicine (UABHM) and UAB Health System (UABHS) reduce the likelihood of unplanned readmissions among discharged patients with a diagnosis of chronic obstructive pulmonary disease (COPD) and/or chronic heart failure (CHF). The project involves the implementation of a series of 7 telemedicine visits over 3 months to 35 patients recently discharged from UAB Hospital Medicine.

The Intervention Prior to discharge from the hospital 70 eligible patients will be recruited by physicians who are a part of the hospital medicine service. Thirty-five patients will be assigned to a treatment group and 35 patients to a control group. Consent will be obtained prior to discharge

Intervention Group: Either prior to discharge or during an initial phone call once they are home, patients will be introduced to the telemedicine technology platform. They will also be asked to complete a baseline survey that asks questions about the care transition process from the hospital to home, informational support, physical function, self-efficacy, and emotional distress. An appointment will be set for the patient's first visit with the care transition intervention team.

During the initial first visit, the advanced practice provider will conduct a medical assessment, the social worker will assess living and psychosocial conditions. The pharmacist

The transition of care team (pharmacist, advanced practice provider, social worker) will conduct an initial visit as a team with the patient using the telemedicine platform. During the visit, the team will assess the clinical, social, and pharmaceutical needs of the patient. The pharmacist will conduct medication reconciliation with a review of the patient's medication profile in totality and cross comparing the medications with all comorbid disease states to assure that no additional medications are warranted at that time. The pharmacist will then run the medications through a number of trusted databases such as Lexicomp or Clinical Pharmacology to confirm that there are no harmful drug-drug interactions that require modification prior to discharge.