JMIR Publications

ABSTRACT

Background:

Among 36 million hospitalizations that occur each year in the United States, >5 million return for unplanned readmission within 30 days of discharge. Although, prevention of readmission due to clinical and procedural factors are considered, there has not been a sufficient focus on improving patient engagement to reduce readmissions. Poor patient engagement by the hospital clinical team results in the lack of knowledge of the disease and treatment in patients that further lead to inadequate self-managed care for recovery during the post-discharge period.

Objective:

The objective of this study was to assess proof-of-concept of a digital healthcare management ecosystem that allow human and digital interactions to reduce unplanned readmissions by providing comprehensive post-discharge care to individuals discharged after major surgery.

Methods:

Post-discharge care was through digitized tailored care pathways provided by 19 care coaches (1 for 50 patients) supported by a digital expert medical team. We tested our digital ecosystem from January 01, 2019 to December 31, 2019 in cardiac and orthopedic surgery departments, Fortis Hospital, Bangalore, India. The first six months was the testing period where the system was deployed, tested in real-world, and refined using feedback. The testing period was followed by six months of evaluation period.

Results:

A total of 152 patients were provided digital care during testing and 648 patients during the evaluation period. During a 30-day follow up after discharge, 80/800 (10%) communicated clinical complaints, and 39 were readmitted (4.9%).

Conclusions:

Our results demonstrate feasibility and proof-of-concept of a comprehensive digital post-discharge care ecosystem, a unique innovative solution to reduce unplanned readmission rates and subsequently reduce healthcare costs. However, an important part of effectiveness of post-discharge care remains in testing our solution in large clinical studies