e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients (Alabama)

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Summary:

For patients with complex medical conditions, the transition from hospital to home-based care is a vulnerable period during which the patient is at high risk for adverse events including medical errors. The Care Transition Intervention (CTI) was developed to address this problem. CTI utilizes a nurse to conduct home visits, telephone followup, and provide assistance at and after discharge with medication self-management, maintenance of a personal health record, timely followup with primary or specialty care, and identification of "red flags" indicative of a worsening condition. Studies examining the CTI report that it is a successful program. However, it is costly and not feasible in settings serving geographically dispersed populations.

Dr. Ritchie and her team developed a cost-efficient technological solution based on the CTI: an interactive voice response (IVR)-supported care transition coaching intervention, e-Coach, that supports medical patients with complex conditions as they transition from hospital to home-based care. The e-Coach, using the TeleSage software application, supports patients through medication self-management assistance, maintenance of a paper-based personal health record, timely followup with primary or specialty care, and the creation of red flags. Patient red flags were identified in the IVR system when patients noted problems with medications, inability to obtain a followup appointment, worsening symptoms, or confusion about their personal health record. The care transition nurses called patients with red flags and helped them with their problems. The e-Coach has a Web-delivered monitoring dashboard that displays meaningful data for the care transition coach to use to monitor patient status, listen to patient messages, and record responses.

In this project, the intervention was evaluated through a randomized controlled trial involving patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) who were discharged from a large tertiary hospital. Rehospitalization rates at 30 days, days in the community, and costs for patients randomized to the intervention and those randomized to usual care were compared.

There was no difference in the primary outcomes for CHF, but intervention patients with COPD had significantly fewer days in the hospital at 30 days and had lower rehospitalization rates. In addition, the team found that use of the intervention was high and that many red flags were identified in both the CHF and COPD patients. For the first call, 63 percent of the intervention patients had one or more red flags, suggesting a real need for post-discharge care and followup.

e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017786
  • Project Period: 
    September 2008 – March 2012
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 299.02 KB)

Summary: For patients with complex medical conditions, the transition from hospital to home-based care is a period during which the patient is at high risk for adverse events, including medical errors. The Care Transition Intervention (CTI) was developed by Eric Coleman and colleagues to address this problem. CTI utilizes a nurse to conduct home visits, telephone followup, and to provide assistance at and after discharge with medication self-management, maintenance of a personal health record (PHR), timely followup with primary or specialty care, and identification of “red flags” to indicate worsening conditions. Studies examining the CTI report that it is a successful program. However, it is costly and not feasible in settings that serve geographically dispersed populations.

Dr. Ritchie and her team developed a cost-efficient technological solution based on the CTI. E-Coach is an interactive voice response (IVR)-supported care transition coaching intervention that supports medical patients with complex conditions as they transition from hospital to home-based care. The e-Coach, using the TeleSage software application, supports patients through medication self-management assistance, maintenance of a paper-based PHR, timely followup with primary or specialty care, and the creation of red flags. Patient red flags were identified in the IVR system when patients noted problems with medications, inability to obtain a followup appointment, worsening symptoms, or confusion about their PHR. The care transition nurses called patients with red flags and helped them with their problems. The e-Coach has a Web-delivered monitoring dashboard that displays meaningful data for the care transition coach to monitor patient status, listen to patient messages, and record responses.

In this project, the intervention was evaluated through a randomized controlled trial involving patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) who were discharged from a large tertiary hospital. Rehospitalization rates at 30 days, number of days in the community, and costs for patients randomized to the intervention and those randomized to usual care were compared.

Specific Aims:

  • Develop an IVR intervention to support care transitions in complex CHF and COPD patients. (Achieved)
  • Randomize patients to an IVR-supported Care Transition program (“e-Coach”) versus usual care comparison. (Achieved)
  • Evaluate use of e-Coach by patients and health care providers. (Achieved)
  • Evaluate the impact of e-Coach versus comparison on patient outcomes, including community tenure. (Achieved)

2012 Activities: While recruitment ended at the beginning of December 2011, the 90-day followup period for the last participant ended on February 29, 2012. The remaining 2012 activities included data collection, data analysis, and final report development. As last reported in the AHRQ Research Reporting System, project progress was on track and budget spending was on target. The project ended in March 2012.

Dr. Ritchie and her research team published a paper in the November 2012 volume of Contemporary Clinical Trials describing the protocol for developing and testing E-Coach: The E-Coach transition support computer telephony implementation study: Protocol of a randomized trial.

Impact and Findings: There was no difference in the primary outcomes for CHF, but intervention patients with COPD had significantly fewer days in the hospital at 30 days and had lower rehospitalization rates. In addition, the team found that use of the intervention was high and that many red flags were identified in both the CHF and COPD patients. For the first call, 63 percent of the intervention patients had one or more red flags, suggesting a real need for post-discharge care and followup. At the close of the study, the coaches were hired to provide care transition coaching throughout the hospital.

Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Congestive Heart Fail- ure, Elderly*, Medicare, Racial/Ethnic Minorities*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

e-Coaching: Interactive Voice Response (IVR)-Enhanced Care Transition Support for Complex Patients - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017786
  • Project Period: 
    September 2008 - June 2012
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 198.86 KB)

Summary: When complex patients transition from hospital to home-based care they are at high risk for adverse events, including medical error. Studies examining the care transition intervention (CTI), for which nurses conduct home visits, telephone follow-up, and provide assistance at and after discharge, report that although it is a successful program, it is costly and not feasible in settings serving geographically dispersed populations.

Dr. Ritchie and her research team developed a CTI-based, cost-efficient technological solution that uses an interactive voice response (IVR)-supported care transition coaching intervention, called e-Coach, which supports medical patients with complex conditions as they transition from hospital to home-based care. e-Coach uses the TeleSage software application and maintains a paper-based personal health record (PHR), provides patient medication self-management assistance, timely follow-up with primary or specialty care, and "red flags" when the patient's condition deteriorates. e-Coach has a Web-delivered monitoring dashboard that displays meaningful data for the care transition coach to use to monitor patient status, listen to patient messages, and record responses. The team is performing a randomized control trial (RCT) involving patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) and who are discharged from the hospital. If e-Coach is successful, it is likely to be disseminated easily and might reduce medical errors in the hospital-to-home transition period as well as risks and costs of rehospitalizations.

Specific Aims:

  • Randomize patients to compare the e-Coach intervention with usual care. (Achieved)
  • Evaluate the use of the e-Coach system by patient and health care providers. (Ongoing)
  • Evaluate the effect of e-Coach on patient outcomes, including 90-day rehospitalizations, successful community tenure at home after discharge from the hospital, and patient self-efficacy based on the Care Transition Measure. (Ongoing)
  • Quantify the costs associated with the e-Coach intervention. (Ongoing)

2011 Activities: Activities related to the ongoing RCT were the main focus of 2011. As of the end of September, 3,428 patients were assessed for eligibility based on hospital census. After two levels of screening, 482 individuals with CHF or COPD were enrolled and randomized. Of these, 248 received usual hospital discharge care, and 234 received the e-Coach intervention. Data collection occurred at 1-week, 1-month, and 3-month intervals following discharge. By the end of the year, 182 participants completed the intervention (in-hospital coaching, all IVR surveys, and follow-up with nurse-coaches as needed). Recruitment ended at the beginning of December. The last participant will end the 90-day follow-up period on February 29, 2012, and appropriate measures have been taken to ensure the final data collection call is completed that day.

The team made several updates to the data collection tools including: 1) developed a specific coding schema to label events leading to disenrollment or discontinuation of the study because participants no longer met inclusion criteria (e.g., implantation of a ventricular-assist device, pregnancy, etc.); 2) added drop-down calendars to data collection forms to calculate health care utilization by specific access dates; and 3) added new data collection forms to examine changes in inclusion status for participants receiving usual care to ensure balance between randomization arms of the RCT. At the end of the year, the project team began cleaning the data. This included resolving alerts in the data collection system when data were missing or incorrectly entered.

The primary challenge experienced by the team was patient recruitment, mainly due to hospital census limitations and the project's eligibility criteria. The team took several enrollment-increasing measures, including screening-protocol expansion, daily "environmental scanning" of the two study hospitals, and regular communication with staff in areas with high volumes of COPD and CHF patients.

Despite these measures, recruitment was still slower than anticipated, so Dr. Ritchie is using a 6-month no-cost extension to complete the RCT and subsequent data collection. As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track and the project budget spending was on target.

Preliminary Impact and Findings: Preliminary findings include the high receptivity from patients on the intervention, a higher-than-anticipated response rate on the IVR surveys among patients receiving the IVR-supported intervention, and a reduction in the number of rehospitalizations for the intervention versus the control group. In addition, the use of IVR technology rather than in-home nursing care transition support has allowed this project to extend its geographic reach, as evidenced by the enrollment of participants from 53 of the 67 counties in the State of Alabama and seven other States.

Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Elderly*, Medicare, Racial/Ethnic Minorities*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

e-Coaching: IVR-Enhanced Care Transition Support for Complex Patients - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017786
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,199,999
  • PDF Version: 
    (PDF, 319.23 KB)


Target Population: Chronic Care*, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Elderly*

Summary: For complex medical patients, the transition from hospital to home-based care is a vulnerable period, where the patient is at high risk for adverse events, including the experience of a medical error or loss of community tenure. Studies examining the Care Transition Intervention (CTI), which provides nurses who conduct home visits, telephone followup, and provide assistance at and after discharge report that it is a successful program but is costly and not feasible in settings serving geographically dispersed populations.

Dr. Ritchie and her team developed a cost-efficient technological solution that is based on the CTI: an interactive voice response (IVR)-supported care transition coaching intervention, e-Coach, that supports complex medical patients as they transition from hospital to home-based care. The e-Coach, using the TeleSage software application, supports patients with medication self-management assistance, maintenance of a paper-based personal health record (PHR), timely followup with primary or specialty care, and identifies ‘red flags’ indicating worsening of the patient’s condition. The e-Coach also has a Web-delivered monitoring dashboard which displays data in a meaningful way for the care transition coach to monitor collected patient data, listen to patient messages, and record responses. The team is currently performing a randomized control trial (RCT) and recruiting patients with congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD) who are discharging from the hospital. During 2011, the team will be completing the trial and evaluating the use of the e-Coach by patients, as well as evaluating the impact of the e-Coach on patient outcomes, including 90-day rehospitalizations, successful community tenure over a 3-month period, medication discrepancies, and patient self-efficacy. In addition, the investigators will quantify the cost associated with the e-Coach. If e-Coach is successful, it is likely to be easily disseminated and could result in substantial avoidance of medical errors in the hospital-to-home transition period, along with notable reductions in the risks and costs of rehospitalizations.

Specific Aims:
  • Randomize 720 patients to the e-Coach intervention or to usual care. (Ongoing)
  • Evaluate the use of the e-Coach system by patient and health care providers. (Ongoing)
  • Evaluate the effect of e-Coach on patient outcomes, including 90-day rehospitalizations, successful community tenure at home after discharge from the hospital, and patient self-efficacy based on the Care Transition Measure. (Ongoing)
  • Quantify the costs associated with the e-Coach intervention. (Ongoing)

2010 Activities: Pilot testing of the e-Coach intervention, also called the UAB Back to Home Support Program, for patients with CHF was conducted in December 2009. After minor refinements were made to the dashboard and IVR system and tested, Dr. Ritchie and her team began study recruitment for the RCT in February 2010. In April and May 2010, the team implemented the pilot for patients with COPD to test feasibility and gather feedback from COPD patients on the use of the system, enunciation of questions, and ease of understanding question options. The dashboard for the COPD group was completed and the team began recruiting COPD patients during the summer.

The primary challenge experienced by the team relates to recruiting patients, mainly due to hospital census limitations and by their eligibility criteria. The team initiated several approaches to increase their enrollment rate, including expanding the screening protocols, engaging in daily “environmental scanning” throughout the two study hospitals, and communicating regularly with staff in areas with high volumes of COPD and CHF patients. In addition, they adjusted Care Transition Coach schedules to increase the availability of coaches for evening and weekend participant recruitment. Finally, research assistants trained in motivational interviewing to enhance skills in overcoming potential barriers to enrollment and as a strategy to increase effectiveness of the enrollment process.

As of the end of December 2010, the team enrolled 330 patients in the study representing 47 of the 67 counties in Alabama and seven surrounding States, demonstrating that the intervention effectively bridges geographic boundaries. Data collection is scheduled to occur at 1 week, 1 month, and 3 months following hospital discharge. The response rate for followup calls and data collection at the 90 days post discharge time is 94 percent. While recruitment is below their goal of 720 participants, the team is pleased with their less than 10 percent attrition rate and 82 percent IVR survey completion rate.

The team refined the data collection tool used for enrollment and capture of baseline data to minimize potential data entry errors and to be more visually distinct and user-friendly. Several data entry fields within close proximity to one another were moved to provide a less cluttered visual presentation and to minimize potential error during the data entry process.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Progress is on track in some respects, but not others, and the project budget is somewhat underspent, 5 to 20 percent. There were delays in programming of the IVR software and e-Coach dashboard in 2009, leading to delays in the initiation of the RCT. In addition, as described previously, the project team had difficulty with recruitment of eligible study participants. They have initiated several strategies to increase enrollment and will request a no-cost extension to complete the project.

Preliminary Impact and Findings: Preliminary findings include the high receptivity from patients on the intervention, a higher anticipated response rate among patients receiving the IVR-supported intervention, and a reduction in the number of rehospitalizations for intervention versus the control group. In addition, an impact of this project has been the geographic reach they have been able to achieve through the use of IVR technology as opposed to in-home nursing care transition support as evidenced by their enrollment of participants from 47 of the 67 counties in the State of Alabama, and individuals living in seven different States.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population

e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - Final Report

Citation:
Ritchie C. e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - Final Report. (Prepared by the University of Alabama at Birmingham under Grant No. R18 HS017786). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 205.48 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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