DisCo supports patients in the transition of care from hospital to home to prevent avoidable re-admissions by proactively outreaching to patients post-discharge.

Project Overview

After discharge, patients and their families often experience challenges during the transition of care processes after a hospitalization. DisCo improves communication after discharge by sending the patient or guardian a post-discharge follow up message with a pre-defined set of questions to determine whether they need any follow up assistance from Boston Children’s hospital with post-discharge coordination of care. Patients choose whether to receive a text message or email. The solution has been in use across 4 services since 2013.

Healthcare Context

DisCo addresses vulnerabilities encountered during the transition of care process after a hospitalization, and to assists patients and their families in carrying out care instructions given to them at discharge. While discharge instructions, prescriptions, and plans are meant to provide patients and their families with the knowledge and tools to safely and efficiently transition a patient’s medical management to the outpatient setting, the process exposes patients to potential discontinuity and challenges which may undermine a patient’s care.

In the News

TEAM

Vincent Chiang
Chief, Department of Medicine
Nitin Gujral
Director of Software Development
Soleh Al Ayubi
Technical Lead