SHM Converge Scientific Abstract ePoster Gallery-Improving Post-Discharge Copd Care Using Care Companion

Pdf Summary

This pilot study evaluated Epic’s MyChart Care Companion as a post-discharge tool for hospitalized COPD patients in a large academic health system in Rhode Island from April 2023 to September 2024. The program aimed to detect COPD exacerbations early, reinforce guideline-based outpatient care, and reduce readmissions through structured symptom monitoring and escalation.<br /><br />Patients were identified through a transitions-of-care order in the COPD admission order set. Social workers helped with MyChart activation and in-person enrollment. Participants remained in the program for 3 months after discharge. The study tracked both quantitative outcomes, such as readmissions, medication fills, and follow-up timeliness, and qualitative feedback from case reports and enrollment barriers.<br /><br />The workflow embedded Care Companion into routine discharge processes, with support from providers, care managers, social workers, and IT. Patients received symptom surveys and educational tasks through their smartphones, including content on inhaler use, smoking cessation, vaccination, diet, exercise, and home oxygen use. Responses triggered automated alerts that were triaged by the Care Transitions Team.<br /><br />Results showed that 84 of 224 eligible patients enrolled, while 160 declined. Early qualitative case reports suggested improved understanding of COPD, better inhaler use, more proactive self-management, less anxiety, and greater confidence in health decisions. Patients also valued timely support from the Care Transitions Team and reported improved quality of life, reduced fear of exacerbations, and increased engagement in pulmonary rehabilitation and community programs. Some requested that the program continue beyond the study period.<br /><br />Quantitative outcomes such as readmissions, medication adherence, follow-up completion, and smoking/vaccination status were still being analyzed.<br /><br />Overall, the study found the digital symptom-monitoring pathway feasible and promising, supporting further evaluation of its impact and scalability.

Asset Subtitle

Atin Jindal

Meta Tag

Author List Atin Jindal, Kelly Pan, Nicholas Sawicki, Richard Gillerman

Category Innovations

Concept Epic MyChart Care Companion

Concept Chronic Obstructive Pulmonary Disease

Concept Discharge Workflow

Concept Early exacerbation detection

Concept Pilot Study

Distinguished Non-Finalist

Presenter Organization Brown University Health

Presenting Author Atin Jindal

Track Transitions of Care

Keywords

COPD

MyChart Care Companion

post-discharge monitoring

readmission prevention

symptom surveillance

care transitions

patient enrollment

inhaler education

self-management

digital health intervention

Epic MyChart Care Companion

Chronic Obstructive Pulmonary Disease

Discharge Workflow

Early exacerbation detection

Pilot Study