Identifying Stakeholder Requirements for the Development of an Electronic Care Transitions Tool to Improve Health Outcomes for Patients with Multiple Chronic Conditions.

Abstract

The transition from hospital to home can be a vulnerable and challenging period for patients, especially those living with multiple chronic conditions (MCC), as evidenced by their disproportionately high rates of readmission.¹ Low health literacy, complexity of a new medication schedule, and "post-hospital syndrome" can all contribute to suboptimal adherence to discharge instructions.² Timely and adequate support during transitional care has the potential to prevent adverse events and avoidable hospital readmissions. The use of mobile technology has been shown to improve health outcomes among those living with chronic illness by promoting self-management and adherence behavior.³ However, current digital interventions focus on the long-term management of a single chronic illness, failing to target the pivotal transition from hospital to home and to address the complex care needs required by those living with MCC. In this study, we describe the stakeholder requirement-gathering process used to inform the design of an EHR-integrated electronic tool to effectively address common care transition challenges for patients with MCC.