An Integrated Model of Care Management, Innovative Technology, and Pharmacy Solutions to Improve Transitions of Care for Patients with Acute Venous Thromboembolic Disease

Patients diagnosed with acute venous thromboembolic disease (VTE) are at high risk for complications during post‐discharge transitions of care (TOC). The primary goal of this project is to develop and validate a novel VTE Transitions of Care Bundle that will build on existing care management strategies by integrating innovative and interactive patient‐facing technology and telemedicine tools into care management and post‐discharge patient care. This project will utilize an innovative, cloud‐based, patient‐centered smart phone app to collect patient‐generated data and facilitate communication with the care team. Data from this app and other bundle components will be aggregated in an EMR‐integrated VTE Electronic Dashboard to allow for real time monitoring of medication adherence, patient‐reported symptoms, andappropriate follow‐up.

This project will optimize inpatient care by enforcing evidence‐based practices for treatment of acute VTE, facilitating safe post‐hospitalization TOC by educating patients and engaging them in their care, improving medication adherence, and promoting shared accountability between the patient and the care team. This project will target inpatients on the medical service with a primary or secondary diagnosis of acute VTE. The impact of the bundle on acute VTE care, recurrent VTE and bleeding complications during post‐discharge TOC, cost, and utilization will be evaluated.