Care Transitions App for Patients With Multiple Chronic Conditions

The objective of this study is to widely implement and evaluate the Care Transitions App in a randomized controlled trial. The app the investigators designed for patients with multiple chronic conditions has four envisioned modules: 1) falls-reduction content, 2) a digital post-discharge transitional care plan (e.g., after hospital care plan, including education, medications, follow-up appointments, warning signs to watch for, nutrition, and other care plan activities), 3) a new module for patients with MCC (diabetes, congestive heart failure, and chronic kidney disease) including condition-specific post-discharge care plans with relevant symptom management activities, 4) a new post-discharge report module which summarizes key care transition findings and allows for patients to enter notes and questions for their providers and their own goals for recovery.

Inclusion Criteria: * Adult patients (55+) with a Brigham PCP or appointment in one of the 15 locations discharging from a BWH general medicine unit * Discharging to home, home health care service or assisted living * Fluent in spoken English in patient or healthcare proxy * Patients with at least one of the conditions listed below + one additional chronic condition on the problem list. * Patient with heart failure on the problem list * Patient with type 2 diabetes on the problem list * Patient with chronic kidney disease on the problem list Exclusion Criteria: * Adult patients (55+) with Westwood, Pembroke, or Transition Clinic PCP admitted to ICU, OBGYN, Surgical, Cardiology, Oncology, Orthopedics, or other Specialty Unit * Pregnant * Prisoner, institutionalized individual or in police custody * Discharge planned within 3 hours of screening * Patient too ill to participate or with active psychosis/serious mental illness, delirium, or severe dementia * Not fluent in spoken English in patient and health proxy * Unlikely to be discharged to home * Lacks a device capable of accessing the app * Lack of a working telephone for 30-day follow-up