Digitally Enabled Transitional Care Management in Oncology

Area of Science:

• Oncology
• Digital Health
• Health Services Research

Background:

• Improving care transitions for cancer patients post-discharge is crucial for quality care.
• Digital monitoring, including remote patient monitoring (RPM), offers potential for enhanced transitional care through better communication and symptom management.
• RPM interventions are underutilized in oncology patient care after hospital discharge.

Purpose of the Study:

• To implement and evaluate a remote patient monitoring (RPM) intervention for medical oncology patients after hospital discharge.
• To assess the feasibility, appropriateness, and acceptability of the RPM intervention.
• To examine the initial effects of the intervention on acute care visits and return on investment.

Main Methods:

• A RPM intervention was implemented to identify oncology patients at discharge, monitor symptoms for 10 days, and intervene as needed.
• Feasibility was defined as >50% patient engagement with symptom assessment.
• Appropriateness was assessed by symptom alerts, and acceptability by a net promoter score >0.7.

Main Results:

• The study evaluated 2,257 medical oncology discharges (1,857 patients) from January 2021 to December 2022.
• 65.9% of discharged patients completed at least one symptom assessment, and 45.5% generated severe symptom alerts.
• Patients reported high satisfaction (Net Promoter Score of 84%). Preliminary analysis showed a nonsignificant 5.8% decrease in 30-day readmissions for GI malignancy patients.

Conclusions:

• Digital transitional care management using RPM is feasible for oncology patients.
• The intervention demonstrated a substantial symptom burden in patients transitioning home.
• While associated with high patient satisfaction, the intervention requires further refinement to impact 30-day readmissions effectively.