With significant advances in prenatal and postnatal care, an increasing number of premature infants and infants with complex medical problems survive to be discharged from the neonatal intensive care unit (NICU). The immediate period after leaving the NICU is critical for parents as they move from the hospital environment to the home setting and is the period in which parental knowledge, skills, and resources can have tremendous impact on an infant's outcome. In a collaboration of UTHealth's McGovern School of Medicine together with the School of Biomedical Informatics (SBMI), we will develop a telehealth application, MyInfantCare, that will provide tailored and adaptive content in an accessible and engaging format to support families and clinicians during the period leading up to NICU discharge through their initial visits with outpatient healthcare providers. Utilizing SBMI's existing digital health framework, Digilegos, we will incorporate customizeable digital modules spanning the evolving needs of infants, parents, and healthcare providers in a tool that will grow with the requirements of care coordination for high-risk infants in their transition from the NICU to home.

   CareLoop's Safe Discharge Communication Pathyway, empowered by the interoperable CareLoop^® platform, ensures safe transitions in care for patients and care team members. Applying an agile approach to person-centered design, rapid prototyping, and advanced informatics methods, HL7/SMART on FHIR, with a modern asynchronous interoperable communication platform, the innovative solution provides closed-loop and context-specific communication between the patient and family caregivers and hospital, primary care, and community partner care teams throughout the hospital discharge to home transition in care. In this Challenge, design partners will address the information-sharing needs, burdens, and gaps for patients with three emblematic chronic conditions (congestive heart failure, hypertension, and depression) with low health literacy and low English-language proficiency. The team will consider the COVID-19 public health emergency and the consequences of social isolation on care transitions and alter as needed the approach to the solution design.

  Our objective is to better support the needs of   patients returning home after hospitalization by engaging them in anticipatory planning and connecting them and those in their support network—family, friends, neighbors, outpatient providers—to community-based resources. The Going Home Toolkit electronic resource planner will utilize connections to the United Way 211 referral service and the patient's personal health record to enable efficient communication of post-discharge needs, referrals to supportive services, and systematic capture of patients' supportive resource information to better understand care transition needs. The Going Home Toolkit is organized around common needs after hospital discharge, such as transportation, medication, errands, meals, housework, personal care, billing and insurance, ongoing information, and support.

Target User: patients, caregivers, clinicians involved in discharge planning and education.

  
Communication and comprehension of medical information is a known barrier in health communication and equity, especially for non-English-speaking caregivers of children with special healthcare needs. We employed user-centered design in understanding the problems identified by our complex care team members. After exploring the use of medical interpreters, the lack of interpreter service accessibility and translation technology maturity, our team at Nationwide Children's Hospital proposed to develop an EHR-integrated, multimodal (voice-interactive and text-based) communication and translation app, called Caawin, to enable non-English-speaking caregivers and providers to communicate with each other using their preferred languages. Caawin is initially intended to support Spanish-speaking families.

  WeWa.life is a personal health navigator platform designed to address underserved individual and virtual health community needs. An intuitive phone app enables health consumers to be in control, informed, entertained, engaged, and activated around the most important thing in their life—their health. The WeWa.life Cloud platform provides a single point of integration with existing health consumer systems using open APIs and an interoperable system architecture. Our WeWa.life is developing a user-centered design solution incorporating behavioral science and interoperable digital health technology to provide a hyperpersonalized approach to managing health and improving medical outcomes. The platform has six Health Goal pathways. for the AHRQ Challenge, we are focusing on the Conditions and Medication pathway, which will address medication reconciliation, adherence, and care transition.