This research project is in progress. PCORI will post the research findings on this page within 90 days after the results are final.

What is the research about?

Having multiple chronic, or long-term, health problems can make it more likely that patients who’ve had an infection, such as pneumonia, return to the hospital after a hospital stay. Monitoring patients at home after they leave the hospital may keep them from having to return. Many hospitals monitor patients by phone. A nurse calls patients two days after they leave the hospital to answer questions and check on medicines and follow-up care. But for patients with multiple chronic conditions, monitoring by phone may not be enough.

In this study, the research team is comparing different combinations of approaches to monitor patients at home. The team wants to learn which approaches keep patients from returning to the hospital:

• Phone calls versus remote patient monitoring, or RPM. In RPM, patients give updates on worsening infection symptoms on a device, such as a tablet or phone. Doctors and nurses receive these data electronically so they can see how patients are doing at home over time.
• RPM by a standard team versus an enhanced team. A standard team includes a nurse and the patient’s doctor. An enhanced team includes doctors, nurses, and healthcare specialists.
• RPM with low versus high support. With low support, patients give updates on the infection only. With high support, patients give updates on the infection plus their chronic conditions.

Who can this research help?

Results may help hospital administrators when considering ways to monitor patients with multiple chronic conditions after a hospital stay.

What is the research team doing?

The research team is enrolling 1,668 patients from 18 hospitals in Pennsylvania. Patients are at medium or high risk of returning to the hospital with an infection or symptom related to a chronic condition. The team is assigning patients by chance to one of five groups.

In group 1, patients receive monitoring phone calls from a nurse.

The other four groups use RPM.

In group 2, patients receive low support monitoring from a standard team.

In group 3, patients receive low support monitoring from an enhanced team.

In group 4, patients receive high support monitoring from a standard team.

In group 5, patients receive high support monitoring from an enhanced team.

The research team is following patients for three months after they leave the hospital to see if they return for any reason.

The research team is looking to see how well each approach to monitoring works for patients of different ages and genders, with different chronic conditions, and for those who live alone or with someone else.

Patients and members of community organizations are giving input on the study.