The eCare App creates an individualized patient care plan in real time by electronically capturing and measuring post-acute stroke functional and social determinants of health. This aligns with national efforts to bring patient-reported outcome measures to the front lines of clinical care, with the goal of improved quality of care and reduced hospital readmissions.
Stroke survivors have a high risk of complications that can impact post-stroke care and recovery. These include physical, cognitive, emotional and social challenges as well as variability in caregiver support. Despite these complexities, standards for quality of stoke care following hospital discharge do not exist, often leading to poor outcomes and increased hospital readmissions.
In an effort to improve health outcomes and care coordination for chronic conditions, the Centers for Medicare & Medicaid Services now provide reimbursement incentives for non-visit-based payment for chronic care management. To comply, providers must maintain a comprehensive, patient-centric care plan that includes functional, cognitive and environmental assessments, support systems and resources.
Researchers at Wake Forest Baptist Medical Center have developed the eCare App, a patient-centered electronic application that captures the social and functional determinants of an individual’s health at the point of care. Designed to be administered by a clinician, caregiver or provider in a clinical or home setting, the tool also assesses caregiver abilities and resources critical for patients during the post-stroke care period. Housed as a web-based or iPad application, the functional assessment is simple to administer, yet provides a comprehensive overview of potential barriers that can impair a patient’s ability to manage their personal health and recovery.
The application’s unique algorithm generates a personalized patient care plan, called an eCare Plan, in real time from survey responses, immediately identifying and recommending specific areas where additional care interventions or support services would benefit the patient. This information drives the coordination of appropriate medical, rehabilitation or community resources to improve the patient’s function, independence and quality of life.
Future developments focus on integrating the eCare App into electronic health records, making it a valuable tool for the consistent delivery of high-quality, personalized patient care.
- Real-time, patient-reported measure of functional and social determinants of health creates a comprehensive, individualized care plan
- Simple, convenient, user-friendly
- Improved care coordination
- Improved post-stroke health outcomes
- Reduced hospital readmissions
- Inexpensive to implement and administer
The eCare App would be useful for most chronic medical conditions (especially conditions where cognitive, social and functional abilities impact recovery) with the development of eCare Plans for each condition that would integrate into the app’s platform. eCare Plans for post-surgical recovery and care transitions are currently being developed.
The eCare App can be used in a wide range of health care settings, including:
- Care transition services
- Primary care
- Assisted living
Stage of Development
The app is developed and is being tested in a multisite clinical trial.
- Pamela Duncan, PhD, Neurology
- Cheryl Bushnell, MD, Neurology
- Scott Rushing, Public Health Sciences
- Ralph D’Agostino, PhD, Public Health Sciences
Vinay Tannan, PhD
Reference #: 15-50