Synopsis of the literature

Multiple chronic conditions

Although prevalence varies by definition, data from AHRQ’s Medical Expenditure Panel Survey indicate that one in three American adults and four in five adults age 65 and older are living with multiple chronic conditions (MCC). Low-income and minority populations have a higher prevalence of MCC and get them at earlier ages. Multiple chronic conditions often encompass comorbid mental and physical health conditions, such as depression, diabetes, and cardiovascular disease. Factors that contribute to the burden of illness among people with MCC include disease severity, functional impairments and disabilities, syndromes such as frailty, and social factors such as homelessness or lack of social support. The preponderance of evidence suggests that people with MCC have lower health-related quality of life and higher total and out-of-pocket expenditures. Care transitions represent a greater burden for people with MCC as they must plan, pay, and attend multiple appointments with providers from different specialties, including physical and mental health, which are often treated in silos. Patients and caregivers navigate a complex and often fragmented care system that places the burden of arranging transportation and synthesis of multiple care instructions on them. Often times, there is no single point of navigation that assists patients and caregivers in interpreting multiple instructions from providers and prioritizing treatment adherence, which can lead to difficulty in deciding which care to prioritize. Such a complex patient may be someone with cardiovascular disease, Alzheimer’s disease and related dementias, with depression, diabetes, and at a high risk for falls. In such a case, the patient and caregivers would need to coordinate multiple services and arrange follow-up care with multiple providers as they transition from one setting to another. Currently, interoperable digital health tools are underutilized in supporting patients and caregivers in making these types of transitions, and connecting people to the resources that they need to manage their MCC during care transitions.

The need for interoperable digital health solutions to support care transitions

The Centers for Medicare & Medicaid Services has recently released new discharge planning process requirements for Critical Access Hospitals and Home Health Agencies to support care transitions. Revised language now requires that, in order for an entity to discharge the patient, they shall transfer or refer the patient where applicable, along with his or her necessary medical information (current course of illness and treatment, post-discharge goals of care, and treatment preferences), not only to the appropriate post-acute care service providers and suppliers, facilities, agencies, but also to other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This recent guidance underscores the need for interoperable digital health platforms to facilitate the seamless transfer of data and information to support care transitions for people living with MCC.

Care transitions happen across a continuum from hospital to home, hospital to long-term care, long-term care to home care, from outpatient to the emergency department, and ultimately to life at home with fully outpatient social services and supports. Mitchell et al. assessed patient preferences and understanding of care transitions, finding that patients value feeling cared for and cared about by medical providers, having unambiguous accountability from the health care system, and want to be prepared and capable of implementing care plans. In order to be able to manage care at home after a hospitalization, patients, their families, and caregivers need to know and understand the plan of care, including medications, physical/occupational therapy, and follow-up appointments. Furthermore, coordinating the next steps of medical care and social supports are important considerations. Social supports are considered to be services such as “meals on wheels,” adult day care, or other specialty custodial care, caregiver reprieve services, non-emergency medical transportation, and connections to other organizations that support activities of daily living. Establishing a single clinical point of contact for every medical and social service may not be possible, but streamlining the remittance of discharge information to patients, families, and caregivers can assist in ensuring that patients/families/caregivers have the information they need to make decisions.