JMIR Publications

ABSTRACT

Background:

The transition from hospital to home and primary care is a vulnerable period, particularly for older patients. Telemedical interventions may improve adherence, symptom management, and satisfaction, but evidence on their role in bridging hospital-to-primary-care transitions remains limited.

Objective:

This study implemented and evaluated a telephone-based follow-up program aimed at supporting the transition from hospital to home and primary care, with a focus on patient health, as well as patient and healthcare provider satisfaction.

Methods:

This prospective, single-center intervention study (University Hospital of Basel, September 2022 – December 2024) enrolled 234 patients discharged from emergency unit or internal medicine wards. Participants received structured telemedical follow-up by a telemedicine provider for up to 10 days before transition to primary care. Primary outcomes were patient health and satisfaction; the secondary outcome was healthcare provider satisfaction. Data were collected via PROMs, PREMs and provider records, and analyzed descriptively and analytically (P<.05).

Results:

Of 9,162 patients screened, 234 were included (43.2% female; mean age 64.8 years). Per-protocol completion was achieved by 62.4%. PROMs indicated significant improvements in patient health from baseline to final follow-up (mean difference −0.28, P<.001), with no deterioration observed. PREMs showed significant improvements in patient satisfaction from baseline to both first and final teleconsultations (mean differences 0.76 and 0.95, P<.001). Healthcare provider satisfaction varied, with telemedical physicians reporting the highest scores, hospital physicians intermediate, and general practitioners the lowest, citing challenges in information transfer and added value.

Conclusions:

Telephone-based follow-up can strengthen continuity of care and improve patient outcomes after hospital discharge, while achieving high satisfaction among patients and healthcare providers. Future research should examine its impact on patient safety, particularly regarding adverse events, and assess cost- and time-effectiveness in multicenter settings. The integration of mobile monitoring tools and subgroup-stratified analyses may further increase the precision and applicability of such interventions. Clinical Trial: The Study is registered in the Swiss National Clinical trial Portal and on clinicaltrials.gov, which is listed in the WHO International Clinical Trials Registry Platform.