People who have been in the hospital for sepsis or pneumonia often have multiple chronic conditions and often have to return to the hospital for additional care. If healthcare providers could monitor a patient at home after the patient leaves the hospital, they could intervene if the patient gets sicker in order to keep them from having to come back to the hospital. However, there are several types of interventions that are currently used to monitor patients, and which ones work best for which groups of patients has not yet been determined.
Structured telephone support (STS) works well but may not be enough for patients who are very sick or at risk for returning to the hospital. Remote patient monitoring (RPM) platforms transmit patient data electronically to providers, which lets them see how patients are doing over time. Usually, RPM platforms monitor one disease or condition, such as heart failure (RPM-Low). Since most patients with sepsis or pneumonia also have other chronic conditions, another option is to use RPM to monitor multiple conditions, which could be more successful at identifying when a patient starts to get sick (RPM-High).
Additionally, it is not yet known whether using RPM to just alert a provider team (Standard Team) or using it alongside a more intensive patient engagement team (Enhanced Team) is more effective. The goal of this study is to compare multiple types of interventions to determine which ones work best for which type of patient. This information will help patients, caregivers, and others understand which program best meets an individual patient’s needs and goals. The interventions the project team will study are: STS RPM-Low plus the Standard Team response, RPM-Low plus the Enhanced Team response, RPM-High plus the Standard Team response, RPM-High plus the Enhanced Team response.
The team will recruit patients after they are discharged from the hospital, randomize them in one of the five arms, and follow them for 90 days. Based on how early enrollees fare in each of the five arms, the team will adapt how it randomizes so that later enrollees will have a better likelihood of being assigned to an arm that will benefit them. Patient partners and other stakeholders have contributed and will continue to contribute to all phases of the team’s work. The collaborative study team includes a stakeholder co-investigator and an advisory board consisting of patient and stakeholder partners with lived experience similar to that of the study population as well as community organizations and others who are knowledgeable about this population and are committed to this work. Their contributions to research-related activities will be ensured by carefully following patient-centered outcomes research (PCOR) engagement principles.
Other Health Services Interventions
Training and Education Interventions