Introduction: Comprehensive transitions of care, reduce dangerous hospital readmissions. Telehealth offers promise, however few guidelines aid clinicians in introducing it in a feasible way while addressing the needs of a multi-comorbid population. Physician adoptability remains a significant barrier to the use of Telehealth due to data overload, concerns for disruptive workflows and uncertain practices. The methods proposed aid clinicians in implementing Telehealth training and research with limited resources to reach patients who need clinical surveillance most. This study introduces a new workflow for addressing tele-transitions of care, using risk stratification, remote patient monitoring, and patient-centered virtual visits. We propose a new communication tool which facilitates adoption. We take a clinically meaningful approach in assessing avoidable hospital readmissions, which can lead to further quality improvements and improved patient care.
Methods: This study design is a parallel-group, superiority, randomized controlled trial in which 180 patients are enrolled in the standard of care or Telehealth arms and evaluated for 30-days post hospitalization. The Telehealth group receives daily vitals surveillance with a "teledoc", a senior resident physician, who performs weekly virtual visits. The endpoint is 30-day hospital readmission. Patient data is collected on hospital utilization, patient self-management, physician and patient experience.
Discussion: Our protocol introduces a novel study design with existing clinical trainees, to provide comprehensive tele-transitions of care to reduce avoidable readmissions.
Keywords: Readmissions; Remote patient monitoring; Telecare; Telehealth; Telemedicine.