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 multicomponent intervention including a Care Transitions App and Digital Navigator training aimed at supporting safe care transitions for patients with multiple chronic conditions and a toolkit to support widespread dissemination.

NARRATIVE Care transitions are a vulnerable period for patients, leading to post-discharge adverse events, falls, medication errors, and readmissions. Specific challenges such as poor communication among inpatient providers, patients, and the primary care team, poor quality and timeliness of discharge documentation, and suboptimal patient understanding of care plans can be improved with our proposed Care Transitions App. In a cluster randomized control trial, we will evaluate the App’s efficacy in engagement of patients and families in their health care and the App’s role in the reduction in adverse events post-discharge.