SHM Converge Scientific Abstract ePoster Gallery-A Pilot Clinical Trial of a Multicomponent Care Coordination Program to Improve Post-Discharge Sepsis Survivorship Outcomes

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This pilot clinical trial evaluated a multicomponent care coordination program aimed at improving outcomes for sepsis survivors after hospital discharge. Sepsis is a major cause of 30-day unplanned readmissions, and the study explored whether telehealth support could reduce this risk.<br /><br />From October 2022 to August 2023, patients admitted with sepsis at UF Health Shands Hospital were recruited. Consented patients received a vital signs kit, discharge education, support from a health coach, and two follow-up telehealth visits. The intervention group included 30 patients who completed at least one telehealth follow-up. Their outcomes were compared with a historical control group of 70 patients who received usual care.<br /><br />The primary outcomes were 30-day readmission, readmission due to sepsis, and 30-day mortality. In the intervention group, the 30-day readmission rate was 13.3% (4/30), compared with 20% (14/70) in the control group. This difference was not statistically significant, though univariate analysis suggested a lower risk of readmission in the intervention group (OR 0.66). There were no deaths in either group.<br /><br />The study found that the intervention was feasible and showed a trend toward fewer readmissions, but the results were not strong enough to prove effectiveness. The authors conclude that larger, adequately powered studies are needed to determine whether this telehealth-based care coordination model truly improves post-discharge sepsis survivorship outcomes.<br /><br />Key takeaways include the usefulness of home vital sign kits for objective telehealth follow-up, the value of health coaches during care transitions, and the potential for targeted interventions in high-risk patient groups.

Asset Subtitle

Juan D. Sarmiento

Meta Tag

Author List Asha L. Bansari, Juan D. Sarmiento, Kiran Lukose, Naveen Baskaran, Nicolas N. Kattan, Nila S. Radhakrishnan

Category Research

Concept Telehealth Care Coordination Program

Concept Sepsis Survivor

Concept Readmission Rate

Concept Readmission Risk

Concept Transitional Care

Distinguished Finalist

Presenter Organization University of Florida

Presenting Author Juan D. Sarmiento

Track Transitions of Care

Keywords

sepsis

care coordination

telehealth

hospital discharge

readmission

sepsis survivors

post-discharge care

health coach

vital signs kit

clinical trial

Telehealth Care Coordination Program

Sepsis Survivor

Readmission Rate

Readmission Risk

Transitional Care