Telehealth Education Leveraging Electronic Transitions Of Care for COPD Patients

Study Overview
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Brief Summary
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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.

Detailed Description
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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) pandemic, most in- home interventions relied on in-person visits, which can be cost-prohibitive and unsustainable. One potential sustainable and scalable solution is to use telehealth for in-home virtual visits; however, use of telehealth for post-discharge TOC interventions has not been routinely implemented. In the post-COVID-19 era, given the rapid expansion of telehealth, hospitals are well-positioned to initiate this virtual care. In-home virtual visits may be particularly promising for patients with chronic obstructive pulmonary disease (COPD), who are often hospitalized, have multiple comorbidities, and require intensive medication teaching due to rampant inhaler misuse. COPD affects more than 16 million US adults, many of whom are older, contribute  $50 billion to healthcare costs annually, experience high rates of acute care revisits, often due to care coordination failures. For this reason, Medicare's Hospital Readmission Reduction Program (HRRP) aims to incentivize hospitals to implement TOC programs for increased quality and value of care for COPD patients. However, currently, such programs fall short of aligning with the full TCM. In-home interventions may be particularly salient for improving medication skills and outcomes for patients with COPD given rampant inhaler misuses, the effectiveness of in- hospital inhaler education, and evidence showing the need for inhaler education reinforcement post discharge. Thus, our trans-disciplinary team proposes to implement and evaluate TELE-TOC: Telehealth Education: Leveraging Electronic Transitions Of Care for COPD patients, which seeks to integrate virtual, pharmacy-based, in-home visits for COPD patients within our hospital's existing COPD HRRP. The central hypotheses are that virtual visits with pharmacists will be feasible to implement and will result in improved medication use and outcomes among COPD patients at high risk for readmission. The investigator aims to iteratively design TELE-TOC using participatory study design and stakeholder input. The study team will then test the effectiveness of adding TELE-TOC virtual visits in a randomized controlled trial among COPD patients enrolled in the HRRP program. Lastly, the study team will develop a plan for a dissemination strategy and roadmap with national stakeholders to facilitate wide scale adoption of TELE-TOC nation wide.

Official Title
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TELE-TOC: Telehealth Education Leveraging Electronic Transitions Of Care for COPD Patients

Conditions
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COPD Exacerbation, Care Transitions

Intervention / Treatment
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* Other: Virtual at Home Medication Reconciliation Visit(s)
* Behavioral: Virtual At Home Medication Education Visit(s)
* Other: COPD advanced practice nurse Inpatient Consult
* Other: Inpatient Medication Reconciliation
* Other: Post-discharge nurse 48 hour phone follow-up call
* Other: Post-discharge follow-up advanced practice nurse outpatient visit


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults 40 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 40 years of age Currently in the intensive care unit

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: 1:1 randomization
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: TELE-TOC plus Usual Care<br>Patients randomized to this arm will receive the TELE-TOC intervention as well as the standard COPD care via the institution's COPD readmission reduction program. | Other: Virtual at Home Medication Reconciliation Visit(s)<br>* Patients will have their medications reviewed by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)<br>* Other names: Virtual At Home Medication Reconciliation;Behavioral: Virtual At Home Medication Education Visit(s)<br>* Patients will be provided with inhaler education by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)<br>* Other names: Virtual At Home Inhaler Education;Other: COPD advanced practice nurse Inpatient Consult<br>* Patients will receive a COPD consult by an advanced practice nurse as part of standard of care<br>* Other names: Inpatient consult;Other: Inpatient Medication Reconciliation<br>* Patients will have their medications reviewed by member(s) of the clinical care team as part of standard of care<br>Other: Post-discharge nurse 48 hour phone follow-up call<br>* Patients will receive a post-discharge nurse 48 hour phone follow-up call as part of standard of care<br>Other: Post-discharge follow-up advanced practice nurse outpatient visit<br>* Patients will be scheduled for a 1-2 week post-discharge visit with the COPD advanced practice nurse as part of standard of care<br>|
| Active Comparator: Usual Care<br>Patients randomized to this arm will receive standard COPD care via the institution's COPD readmission reduction program. | Other: COPD advanced practice nurse Inpatient Consult<br>* Patients will receive a COPD consult by an advanced practice nurse as part of standard of care<br>* Other names: Inpatient consult;Other: Inpatient Medication Reconciliation<br>* Patients will have their medications reviewed by member(s) of the clinical care team as part of standard of care<br>Other: Post-discharge nurse 48 hour phone follow-up call<br>* Patients will receive a post-discharge nurse 48 hour phone follow-up call as part of standard of care<br>Other: Post-discharge follow-up advanced practice nurse outpatient visit<br>* Patients will be scheduled for a 1-2 week post-discharge visit with the COPD advanced practice nurse as part of standard of care<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Correct inhaler technique 30 days post discharge | Correct inhaler technique within 30 days post-discharge compared to baseline technique in hospital based on standardized checklists (<75% correct steps = misuse) | 30 days post discharge | 
| Reach of the TELE-TOC intervention | Proportion of patients receiving at home inhaler education within 1-2 weeks post discharge | 1-2 weeks post discharge | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 30 day revisits | proportion of patients with any emergency department visit and/or re-hospitalization within 30 days of index admission | 30 -days | 
| 90 day revisits | proportion of patients with any emergency department visit and/or re-hospitalization within 90 days of index admission | 90 -days | 
| 180 day revisits | proportion of patients with any emergency department visit and/or re-hospitalization within 180 days of index admission | 180 -days | 
| Medication errors | Proportion of patients with medication errors at TELE-TOC visit medication reconciliation | Within 30 days | 
| COPD Symptoms option 1 | Evaluation of COPD symptoms using COPD Assessment Test (CAT) | Within 30 days | 
| COPD Symptoms option 2 | Evaluation of COPD symptoms using the modified medical Research Council Scale (mmRC) [Scale = 0 to 4; 0 (better) = Breathlessness only on strenuous exercise; 4 (worse)= too breathless to leave the house or breathless when dressing or undressing] | Within 30 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Medication education, Medication reconciliation, Medication Adherence