# Care Transitions App for Patients with Multiple Chronic Conditions

> **NIH AHRQ R01** · BRIGHAM AND WOMEN'S HOSPITAL · 2022 · $400,000

## Abstract

The goal of this project is to create an interoperable care transitions application (Care Transitions App) for
patients with multiple chronic conditions that will bridge the care transition between hospital, home, and
primary care clinic in order to reduce adverse events in the first 30 days after discharge. We propose to
develop a Care Transitions App which will engage patients and caregivers at the two trial sites, Brigham and
Women’s Hospital and Vanderbilt University Medical Center, in both inpatient and primary care settings. The
Care Transitions App will incorporate components from our prior work, specifically falls-reduction content. We
propose to create three new modules: 1) a digital post-discharge transitional care plan, 2) modules for multiple
chronic conditions (MCC: diabetes, congestive heart failure, and/or chronic kidney disease), including
condition-specific post-discharge care plans with relevant lab values and medication education, and 3) a
module for patients to enter their questions and their own goals for recovery prior to the post-discharge clinic
visit. This project will include usability testing and integration of the application with Epic via the fast healthcare
interoperability resources (FHIR) and SMART on FHIR technology at Brigham and Women’s Hospital (BWH) in
Year 1. Aim 1: Utilize participatory design to develop the Care Transitions App and a multi-component
intervention, including person-based and task-based interventions delivered by a Digital Navigator. Aim 2: Pilot
test the Care Transitions App at BWH and disseminate to VUMC. 2a. We will pilot test the Care Transitions
App and use the RE-AIM framework to iteratively refine the intervention before launching the clinical trial at
BWH in Aim 3 (Y2). Later, we will pilot test the Care Transitions App at VUMC (Y5). 2b. We will disseminate
the Care Transitions App at VUMC (Y5) and use the RE-AIM framework to understand barriers and facilitators
at VUMC. Lessons learned at both sites will inform a dissemination toolkit. Aim 3: Evaluate the effectiveness of
the Care Transitions App through a cluster randomized trial enrolling patients over the age of 65 years old with
MCC including diabetes, congestive heart failure, and/or chronic kidney disease. We will test the following
hypotheses: a. The Care Transitions App will be associated with a decrease in the primary outcome, post-
discharge adverse events (falls, adverse drug events, other adverse events) within 30 days of discharge. b.
The Care Transitions App will be associated with improvements in secondary outcomes: 30-day readmissions,
completion of post-discharge phone calls, and completion of post-discharge primary care clinic visits. c. The
Care Transitions App will be associated with improvements in patient-centered outcomes: global health, self-
efficacy for managing chronic conditions, out of pocket costs, Care Transitions Measure 3, patient experience.
Outcome: Our team will develop, evaluate, and disseminate a ...

## Key facts

- **NIH application ID:** 10365310
- **Project number:** 1R01HS028007-01A1
- **Recipient organization:** BRIGHAM AND WOMEN'S HOSPITAL
- **Principal Investigator:** Patricia C Dykes
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2022
- **Award amount:** $400,000
- **Award type:** 1
- **Project period:** 2022-09-30 → 2027-07-31

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10365310

## Citation

> US National Institutes of Health, RePORTER application 10365310, Care Transitions App for Patients with Multiple Chronic Conditions (1R01HS028007-01A1). Retrieved via AI Analytics 2026-05-27 from https://api.ai-analytics.org/grant/nih/10365310. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*