A Clinician-Patient Dual Behavior Change Framework to Leverage Informed Digital Nudges to Reduce Hospital Readmissions and Improve Patient Outcomes: A Trial for Scalable Strategy to Reduce Readmissions (PREVENT-R)

The PREVENT-R trial will evaluate an intervention targeting both clinician and patient behavior. The clinician-focused piece consists of an electronic medical record-based digital nudge presented to emergency department clinicians caring for eligible older adults at high risk of readmission. The nudge is intended to prompt clinicians to consider referral to the Service Navigator Program from the Agency on Aging of South Central Connecticut for patients with needs that may be addressed through community-based services and supports. The study will evaluate whether these mechanisms (clinician referral and patient program acceptance behavior) are associated with subsequent Emergency Department (ED) revisits and 30-day hospital re-admissions.

Inclusion Criteria: Patient Participants: * Hospitalization within the previous 30 days. * Identified as being at high risk for readmission by the EMR-embedded algorithm. * Reside in a geographic area identified as having high health-related social needs based on the Community Health Needs Assessment (CHNA). * For consent-dependent patient research activities, able to provide informed consent. Clinician Participants: * ED clinicians who have experience with the PREVENT-R intervention and/or SNP referral process and are able to provide informed consent for participation in the qualitative interview. Service Navigator Participants: * Individuals involved in delivering SNP services to patients enrolled in or referred through PREVENT-R and who are able to provide informed consent for participation in the qualitative interview. Exclusion Criteria: Patient Participants: * Require immediate hospital admission. * Receiving hospice, skilled nursing facility, or palliative care. * Unable to participate in study procedures in English or Spanish.