Intensive Telemedicine Transitions of Care Clinic: A Prospective Feasibility Study of a Novel Ambulatory Model Serving Appalachian Patients.

Introduction: Hospital discharge is a complex process plagued with medical errors and poor coordination. Disjointed discharges are detrimental to Appalachian patients with access barriers and multiple chronic diseases. Telehealth is a tool used to improve access within rural Appalachia. To address this high-risk transition period, an interprofessional team deployed telemedicine to improve post-hospital care for Appalachian patients.

Purpose: Patients with uncontrolled chronic medical conditions were enrolled into the Intensive Telemedicine Transition of Care Clinic (I-TTC) with a primary outcome of 30-day Emergency Department (ED) presentations and hospital readmissions. Secondary outcomes included improved control of chronic conditions and patient cost savings.

Methods: Patients with uncontrolled chronic conditions were given home-monitoring devices and enrolled in the I-TTC post-hospitalization. Telehealth visits were conducted with an interprofessional team comprised of graduate health science students under the supervision of I-TTC physicians. Hospital readmissions, emergency department (ED) presentations, and chronic disease specific measurements were analyzed through retrospective review.

Results: Sixteen adult patients participated in the I-TTC pilot study from 2021-2022. At baseline all patients with hypertension were uncontrolled. The average HbA1C of patients with uncontrolled diabetes was 11%. Post-enrollment, 12.5% of patients had a 30-day ED presentation or hospital re-admission. The average HbA1c for those with uncontrolled diabetes was 8.1% after I-TTC intervention. Of the ten patients with uncontrolled blood pressure, six were controlled post-enrollment. The average cohort total cost savings was $3,144.35.

Implications: The I-TTC suggests feasibility for an interprofessional team utilizing telemedicine in achieving control of chronic medical conditions through improved access to ambulatory healthcare.