Scaling care coordination through digital engagement: stepped-wedge trial assessing readmissions

Area of Science:

• Health Services Research
• Digital Health
• Patient Care Management

Background:

• Transitions of care after hospital discharge are critical but resource-intensive.
• Traditional telephonic care coordination faces scalability challenges.
• A patient postdischarge digital engagement (PDDE) program was developed to enhance care coordination.

Purpose of the Study:

• To evaluate the impact of a PDDE program on 30-day hospital readmissions.
• To assess PDDE's effectiveness in reducing readmissions for low-risk patients.
• To determine if PDDE could supplement care coordination for medium- and high-risk patients.

Main Methods:

• A pragmatic, stepped-wedge cluster randomized trial involving 5 implementation waves.
• Stratification of 5490 inpatient discharges by readmission risk (low, medium, high).
• Intention-to-treat and treatment-on-the-treated analyses using mixed-effects logistic regression.

Main Results:

• The PDDE intervention did not significantly impact readmission rates across low-, medium-, or high-risk patient groups.
• A treatment-on-the-treated analysis also showed no significant difference in readmissions among PDDE users.
• The study included 5490 discharges (2735 control, 2755 intervention).

Conclusions:

• The PDDE program expanded care coordination resources for low-risk patients previously unable to access such services.
• The PDDE program did not demonstrate a significant impact on reducing hospital readmissions.
• PDDE efficiently increased patient-provider touchpoints, offering a scalable solution for resource-limited settings.