Study: NCT04829188

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Structured Telephone Support (STS)
Description: Structured telephone support (STS) consists of post-discharge assessment, education, and medication reconciliation delivered telephonically by a health plan case manager, home care as needed, and follow-up with the primary care within seven days post-discharge.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Low-intensity Remote Patient Monitoring (RPM-Low)
Description: Questions are pushed to members multiple times per week for up to 90 days post-discharge. Questions are limited to those checking vital signs that indicate worsening of infection. Patient answers to RPM questions trigger High or Medium alerts, which trigger a response by members of the intervention care team.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Low-intensity Remote Patient Monitoring (RPM-Low)
Description: Questions are pushed to members multiple times per week for up to 90 days post-discharge. Questions are limited to those checking vital signs that indicate worsening of infection. Patient answers to RPM questions trigger High or Medium alerts, which trigger a response by members of the intervention care team.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: High-intensity Remote Patient Monitoring (RPM-High)
Description: Questions are pushed to members multiple times per week for up to 90 days post-discharge. Questions include monitoring vital signs for worsening infection but also ask about factors that would indicate worsening of underlying heart or lung conditions, such as weight gain or shortness of breath. Patient answers to RPM questions trigger High or Medium alerts, which trigger a response by members of the intervention care team.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: High-intensity Remote Patient Monitoring (RPM-High)
Description: Questions are pushed to members multiple times per week for up to 90 days post-discharge. Questions include monitoring vital signs for worsening infection but also ask about factors that would indicate worsening of underlying heart or lung conditions, such as weight gain or shortness of breath. Patient answers to RPM questions trigger High or Medium alerts, which trigger a response by members of the intervention care team.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Standard Response Team
Description: RPM alerts are screened by a nurse-staffed call center. Nurses determine whether emergency care is needed. If not, nurses contact the patient and/or the patients' PCP or specialist to coordinate care and ensure timely follow-up.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Standard Response Team
Description: RPM alerts are screened by a nurse-staffed call center. Nurses determine whether emergency care is needed. If not, nurses contact the patient and/or the patients' PCP or specialist to coordinate care and ensure timely follow-up.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Enhanced Response Team
Description: RPM alerts are screened by a nurse-staffed call center. Nurses determine whether emergency care is needed. If not, the call center alerts a multidisciplinary care team that is led by a certified registered nurse practitioner (CRNP). CRNPs, who operate in a palliative care role, have prescribing authority and can modify care plans. In addition to reacting to RPM triggers, team members (e.g., CRNP, social workers, nurses) meet with the patient in-person or virtually in the week after discharge and at least twice more in the next 90 days, conduct assessments and a pharmacy review, develop care plans, and discuss advance directives.

Intervention type: BEHAVIORAL
Group type: ACTIVE_COMPARATOR
Intervention: Enhanced Response Team
Description: RPM alerts are screened by a nurse-staffed call center. Nurses determine whether emergency care is needed. If not, the call center alerts a multidisciplinary care team that is led by a certified registered nurse practitioner (CRNP). CRNPs, who operate in a palliative care role, have prescribing authority and can modify care plans. In addition to reacting to RPM triggers, team members (e.g., CRNP, social workers, nurses) meet with the patient in-person or virtually in the week after discharge and at least twice more in the next 90 days, conduct assessments and a pharmacy review, develop care plans, and discuss advance directives.