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Avoidable hospital readmissions and medical errors are costly and dangerous. Many hospital systems have invested in various transitions of care models, health information systems and now increasingly, in telehealth, to help improve care after hospitalization. Although many models and strategies exist to improve care transitions, very few guidelines address the role of health technology, data analytics and health information exchanges within this process. Few studies have described an optimal workflow for physicians performing virtual clinical surveillance using telehealth. Furthermore, although many published studies have conducted telehealth transition of care interventions for patients with specific disease pathologies, few studies evaluate interventions using multi-modal remote patient monitoring for patients with mixed-chronic conditions. This appears to be an ideal target audience for telehealth interventions given that, the factors affecting patient risks for readmission are often complex and multifactorial. Our study aims to evaluate a new workflow for addressing comprehensive transition of care, using risk stratification, telehealth remote patient monitoring, and patient-centered virtual visits. We also introduce a new communication tool for relaying tele-communication. Aim: To describe current study protocol and demonstrate the steps and stakeholders involved to ensure proper integration and scalability to other practices. Methods: The study is a feasibility study with a randomized controlled trial design, in which an anticipated 180 patients will participate. The treatment group receives technology driven clinical surveillance with a dedicated transition of care physician, along with weekly virtual visits using a telehealth kit, in addition to standard transition of care services. The control group receives the standard of care and follow up within 30 days of hospital discharge. All patients are enrolled in the Health Information Exchange (HIE) and undergo risk stratification. Risk stratification is performed for all patients using two different modalities: An Electronic Medical Record (EMR) based prognostic tool and a validated machine learning algorithm from our biomedical informatics team. The endpoint is 30 day hospital readmission. Patient data is collected on hospital and ED utilization, patient self-management, perceived care coordination and patient experience. Discussion and conclusions: Our study goals are to identify the optimal clinical workflows needed to incorporate telehealth technologies into patient care, and incorporate risk stratification to target patients most at risk for readmission. The specific aim of the study is to determine the generalization and scalability of implementing telehealth services in the post hospital period to improve transitions of care and reduce hospital readmissions. To accomplish our study goals and aim we will provide services in the post-acute period following hospital discharge to evaluate the impact of telehealth on care coordination, patient satisfaction, patient self-management and hospital readmission.

Tele-Transitions of Care: An Approach to Reduce 30-Day Readmission Using Tele-Health Technology; a Randomized Controlled Trial Study Protocol