As the population ages, the need for appropriate geriatric rehabilitation services will also increase [1]. In 2011, older adults (aged 65 years and older) represented 14.4% of the Canadian population, which is expected to continue rising [2]. At the same time, hospitals face constant pressures to discharge patients earlier, which has driven the need for more complex care being delivered in the home [3]. Engaging patients and their informal caregivers in their care is crucial for optimal outcomes during the transitions from hospital to home. This includes patients’ understanding of their specific health conditions, their ability to follow discharge instructions, and their knowledge of what signs and symptoms to watch for to seek medical care [4]. Patients admitted to geriatric rehabilitation often have a diagnosis of cognitive impairment and mild dementia resulting in short-term memory loss. Most of this patient population depend on their informal caregivers to provide support to them during the transition from hospital to home.

Challenges associated with care transitions are complex [5]. Gaps in the quality of care during care transitions include patients (1) leaving the hospital not being equipped to manage their care at home, (2) receiving conflicting information about managing their health condition, (3) leaving the hospital and then being unable to communicate with their health care provider who has their comprehensive health care plan, and (4) not being engaged or involved in decisions related to their care [6-10]. This puts older adults at greater risk of medical complications, including medication errors and lack of appropriate follow-up care [11-15]. In a recent study, older adults communicated the importance of active involvement and meaningful engagement in managing their personalized health needs while transitioning from the hospital to home [16].

The development of new technologies for personalized care could empower patients in managing their health care needs while navigating our complex health care system [17]. Monitoring patients remotely can improve treatment, prevent unnecessary readmissions to the hospital, and engage patients in managing their health conditions [18,19]. The use of mobile health (mHealth) apps has grown significantly, specifically in supporting the management of individual chronic diseases [20]. mHealth apps have been designed and implemented in diabetes [21,22], cardiovascular disease [23], and chronic obstructive pulmonary disease [24] to better engage patients in managing their own health condition. Key features of the care transition processes that lend themselves to an mHealth app solution include personalized discharge and transition plans, information regarding signs and symptoms related to a patient’s medical condition, coordination of care, medication management, exercise planning, medical equipment needs, dietary requirements, lifestyle changes, appointment tracking, home and community care needs, fall prevention strategies, community resources, remote support, and interactive communication with the health care team.

No studies, to our knowledge, have looked at specifically using technology to facilitate the hospital-to-home transition processes to support patients in meeting their personalized needs and in providing them with better integration of care between health care sectors. We hypothesize that a technology-supported person- and family-centered care transition could empower geriatric rehabilitation patients, engage them in shared decision making, and ultimately help them to better manage their personalized needs during care transitions from hospital to home. The purpose of this study is to design and test the feasibility and acceptability of a novel Path to Home mobile app designed to manage the personalized needs of geriatric rehabilitation patients during their transitions from hospital to home.

This study will consist of (1) codesigning a patient- and provider-tailored mobile app, and (2) feasibility pilot testing of the mobile app to manage the needs of geriatric rehabilitation patients when leaving the hospital. In phase 1, we will follow a user-centered design process integrated with a modern agile software development methodology to iteratively codesign the personalized care transition Path to Home mobile app. In phase 2, we will conduct a single-arm feasibility pilot test with geriatric rehabilitation patients using the personalized care transition Path to Home mobile app to manage their needs during the transition from hospital to home.

Bruyère Continuing Care, which offers care to the frail elderly, people with chronic and terminal illness, and persons with disabilities in Ottawa, ON, Canada, has developed a paper-based Path to Home workbook, codesigned by patients and health care providers. Its purpose is to be a central information repository that simplifies partnering health care providers with patients and their informal caregivers in reviewing and ensuring they understand their discharge instructions. This is extremely important to ensuring that prescribed medications are taken correctly, that exercises and lifestyle recommendations are followed, that appointments are kept, and that there is an understanding of the signs and symptoms that necessitate a visit to their primary care team [25]. When discharge instructions are not adhered to, the patient has a much higher probability of being readmitted to hospital [25]. Increasingly, patients and informal caregivers have online access tools (eg, phone, tablet, or laptop computer) with them when the patient is admitted and have asked for their discharge information to be more readily available for review. Although the use of technology by older adults is limited, there have been proven benefits in informal caregivers being able to access discharge instructions to be shared with primary care providers [26]. Other mHealth apps have incorporated the ability to prompt patients by providing reminders and helpful tips and information [27].

Using the evidence-based content developed for the paper-based Path to Home workbook, we will collaborate with NexJ Health Inc (Toronto, ON, Canada), a provider of cloud-based population health management solutions, to design and configure a personalized care transition Path to Home mobile app (a minimum viable product for a mobile phone, tablet, or computer). NexJ Health’s Connected Wellness platform is a well-developed technology solution that is designed to support multichannel communications between patients, informal caregivers, and health care providers. This app has been previously used in 17 research trials and 8 deployment evaluations to support patients in electronically tracking health behaviors and self-monitoring health data [28]. The prototype Path to Home mobile app will (1) allow patients to track progress on their discharge and care transition plans, (2) empower patients in making decisions about their own health and needs, and (3) improve information exchange between providers while patients are transitioning from the hospital to home.

Following the app design and development, we will conduct a single-arm feasibility pilot test of the Path to Home mobile app. The specific objectives are to (1) determine whether it is feasible to provide a mobile app to geriatric patients with hip fractures and their informal caregivers, (2) determine whether a mobile app is acceptable to this population, (3) refine the methods for a larger study.

This proposed research will directly integrate input and feedback from all relevant stakeholders (health care providers, patients, and informal caregivers) in the design and development of a personalized care transition Path to Home mobile app for managing the needs of geriatric rehabilitation patients and facilitating shared decision making. We will use the findings to inform a larger-scale study to develop an understanding of the specific mechanisms by which the Path to Home mobile app is effective for patients and health care providers. We will test the implementation and evaluate the technology-based intervention for effectiveness in a larger randomized study.

This technology-supported care transition management approach has the potential to empower patients, enhance communication with health care providers, and provide better care and better access to relevant resources to improve management of older adults’ personalized needs when discharged from hospital to home. The development of this new technology can potentially help to facilitate the care transition from hospital to home by integrating the app with electronic health records or other standard electronic health applications.

Our findings will help validate the use of this technology for geriatric rehabilitation patients discharged from the hospital to home. This research has the potential to optimize information delivery between health care providers and patients, to provide better access to specific care needs, to prevent unnecessary visits to the emergency department and reduce hospital readmissions, to improve the continuity of care, and to improve patient outcomes and experiences. Future research will more rigorously evaluate the health and economic benefits to inform wide-scale adoption of the technology.