Project Summary/Abstract: We will design and implement a health information technology-enabled system to improve care coordination following an inpatient admission or emergency department visit. Care coordination is required in the absence of continuity of care or when care is fragmented. Americans increasingly live with chronic diseases, and receive care in regions where care is fragmented across care systems and providers. Despite the increasing ubiquity of electronic health records, these systems are often unable to support coordination between clinicians and settings. Resulting failures in care coordination result in billions of dollars in wasteful spending, including outcomes such as hospital readmissions. Although selected care coordination interventions can reduce hospital admissions and improve patient-reported outcomes in chronically ill populations, care coordination programs often fail to achieve their stated objectives and are not globally cost saving. New, potentially replicable approaches to coordinating care are therefore urgently needed. Smartphones may offer a new, more nimble approach to information transfer that facilitates care coordination. Location-sensing technologies are already used in a host of smartphone applications (apps), and have the potential to reliably detect when patients receive care at any hospital or emergency department based on a phone’s Global Positioning System (GPS) coordinates. Following exploratory research by our team, the proposed study will develop and test a new system for care coordination in which a smartphone app sends location-based alerts to care managers at a federally qualified health center when their high-risk patients receive care at a regional hospital or emergency room. We will use a ‘hybrid effectiveness- implementation’ design in which our primary research questions focus on intervention impact and our secondary research questions focus on barriers and facilitators to implementation. The aims of this study are to: 1) Develop a care coordination system in which a novel smartphone app, CHASER (Coordinating Hospital And emergency use with Smartphone-Enabled Reminders), facilitates information transfer and care coordination following inpatient admissions and emergency visits, and; 2) Conduct a feasibility study examining the system’s preliminary impacts and implementation in a care management program for high-risk patients.

Project Narrative (i.e. Public Health Relevance Statement): Failures in care coordination lead to hospital readmissions and billions of dollars in wasteful spending. New care coordination approaches are needed to ensure primary care teams can meet their patients’ needs after transitions between health care settings. In response, we will design and implement a care coordination system in which a smartphone app sends location-based alerts to care managers when high-risk patients receive care at a regional hospital or emergency room.