Making the transition from hospital to home is a difficult undertaking for many patients, particularly those with complex, chronic healthcare needs. There has been a steady increase in the resources that VHA uses to treat chronic heart failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD), both of which are among the most common reasons for admission and re-admission in VHA facilities. Many patients with CHF or COPD can feel overwhelmed by the self-management tasks they must perform at home and face limited support for those tasks post-discharge. Clinicians bear competing demands and thus cannot routinely engage in tailored post discharge follow up with patients beyond the scope of usual care. As a result, many patients are often readmitted to the hospital due to factors such as limited self-monitoring, suboptimal adherence, and lack of follow-up. Multi-component care transition interventions have been shown to be effective in some cases, but can be costly to implement. An alternative approach is to augment care transition interventions with technology.
We are designing and evaluating a technology-assisted care transition intervention founded on the concept of a virtual nurse that interacts with Veterans with CHF or COPD through different technology channels. Building on evidence that care transition interventions having both an inpatient and outpatient component are more effective, the virtual nurse appears on a touchscreen during the inpatient stay and educates Veterans about the important elements of a care transition. After discharge, the virtual nurse coaches patients through two-way, automated, computer-tailored text messaging made possible by VHA's new HealtheDialog system.
Guided by the sociotechnical framework for implementing health information technology, our objectives are to: 1) Refine and test the virtual nurse's onscreen personality and the corresponding touchscreen technology for use with Veterans who have CHF or COPD through a randomized simulation experiment; 2) Conduct a randomized trial of the entire technology-assisted virtual nurse care transition intervention, including the onscreen personality refined in objective 1 and the automated, computer-tailored text messaging; and 3) Evaluate the intervention, including its effectiveness, implementation process, and budget impact.
We will conduct an effectiveness-implementation hybrid type 1 trial at three VA facilities. Although our primary focus will be testing the effectiveness of the virtual nurse intervention, we will also gather information about its delivery and potential for implementation across other VA care settings. Inpatient Veterans with CHF or COPD will be randomized to receive a brief inpatient education video about care transitions (an attention control) versus the virtual nurse intervention.
Following a mixed-methods approach, we will conduct surveys and interviews. Measures will include innovative patient-level "care transition milestones," engagement and activation, sustained community tenure, time to readmission, and 30-day rehospitalization. To understand budget impact, we will measure the costs of staff time and resources required to support the virtual nurse intervention, and the potential costs or savings resulting from changes in use of VHA healthcare services associated with the intervention.
Development of the virtual nurse's onscreen personality, including her physical attributes and a scripted dialogue that drives the interaction with Veterans during their inpatient stay is completed, as is the development of the automated text messaging protocols. We completed beta testing of these intervention components and received positive feedback from the Veterans who participated. One hundred percent of the Veterans who tested the touch screen tablet (n=8) said that interacting with the virtual nurse on the touch screen tablet was easy to do. Similarly, all the Veterans who tested the text messaging protocols (n=5) said that the number of text messages they received each day was just the right amount. Final revisions to the intervention components were made before the launch of the trial at our three sites earlier this year. In addition to these findings from beta testing, we completed site visits, including semi-structured interviews with clinical staff, at our three participating VA facilities, to document factors that could impact implementation of the care transition intervention.
Categories of potential barriers included limited technology use among the target patient population (e.g., aversion to texting, reliance on feature or flip phones making texting cumbersome, and worries about the costs of texting among those Veterans who have limited texting plans); discharge workflows (e.g., the unpredictability of discharge dates and corresponding implications for introducing the intervention, demands on the patients during their inpatient stay including ongoing lab and vital tests, and uncertainty about where a Veteran may be discharged to at the end of their inpatient stay); and the overall complexity and range of potentially competing healthcare needs of the target population (is managing CHF or COPD a Veteran's priority at the time?).
Potential facilitators to address these challenges also emerged during our site visits, and guided the development of our recruiting process. These included having dedicated research staff to introduce Veterans to the intervention and reduce burden on clinical team members, engaging informal caregivers in a supportive role in the intervention to address potential Veteran aversion to texting, emphasizing the ability to use one's own cellular phone for the outpatient portion of the intervention, and finally, emphasizing the novel and innovative aspects of the intervention and the chance to advance use of new VA technologies.
Rehospitalization is common among Veterans with CHF and COPD, and represents a significant expense for VHA. With increasing numbers of Veterans with CHF and COPD being seen for care at VHA facilities, traditional transition interventions may not be sustainable. In alignment with VHA priorities, we intend to improve electronic communications with Veterans, leveraging texting and emerging communications technologies, and to identify how to enhance and increase the use of Veteran-facing technologies. The virtual nurse intervention designed and evaluated in this study is intended to augment existing care transition practices, not replace the roles played by clinical team members. This project stands to have significant impact on the quality, effectiveness, efficiency of VHA services, and Veteran health, and represents a novel approach to speeding the movement of evidence-based care transition approaches into VHA care.
None at this time.
Technology Development and Assessment, Treatment - Efficacy/Effectiveness Clinical Trial, TRL - Applied/Translational
Cardiovascular Disease, Care Coordination, Care Management Tools, Computer Simulations, Cost-Effectiveness, Health Promotion and Education, Implementation, Technology Development