Telehealth Education Leveraging Electronic Transitions Of Care for COPD Patients

Summary

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.

Conditions

• COPD Exacerbation
• Care Transitions

Interventions

OTHER

Virtual at Home Medication Reconciliation Visit(s)

Patients will have their medications reviewed by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)

BEHAVIORAL

Virtual At Home Medication Education Visit(s)

Patients will be provided with inhaler education by the TELE-TOC interventionalist, a member of the pharmacy team (anticipated)

OTHER

COPD advanced practice nurse Inpatient Consult

Patients will receive a COPD consult by an advanced practice nurse as part of standard of care

OTHER

Inpatient Medication Reconciliation

Patients will have their medications reviewed by member(s) of the clinical care team as part of standard of care

OTHER

Post-discharge nurse 48 hour phone follow-up call

Patients will receive a post-discharge nurse 48 hour phone follow-up call as part of standard of care

OTHER

Post-discharge follow-up advanced practice nurse outpatient visit

Patients will be scheduled for a 1-2 week post-discharge visit with the COPD advanced practice nurse as part of standard of care

Sponsors & Collaborators

• Agency for Healthcare Research and Quality (AHRQ)

  collaborator FED

• Washington University School of Medicine

  collaborator OTHER

• Society of Hospital Medicine

  collaborator OTHER

• COPD Foundation

  collaborator OTHER

• Hospital Medicine Reengineering Network (HOMERuN)

  collaborator UNKNOWN

• The American Telemedicine Association

  collaborator UNKNOWN

• University of Chicago

  lead OTHER

Principal Investigators

• Valerie G Press, MD, MPH · University of Chicago

Study Design

Allocation

RANDOMIZED

Purpose

PREVENTION

Masking

SINGLE

Model

PARALLEL

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2025-02-19

Primary Completion

2026-08-31

Completion

2026-12-31

Countries

• United States

Study Locations