• Alexandra Polovneff, Neemit Shah, Abhishek Janardan, Erika Smith, Ivan Pasillas, Natalie Mortensen, Jeana M Holt, Melek Somai, Rodney Sparapani, and Bradley Crotty.
• Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226. Email: bcrotty@mcw.edu.
• Am J Manag Care. 2024 Feb 1; 30 (2): e32e38e32-e38.

ObjectivesTransitions of care are pivotal, vulnerable times as patients are discharged from the hospital. Telephonic care coordination is standard care, but labor intensive. We implemented a patient postdischarge digital engagement (PDDE) program to scale coordination. We hypothesized that PDDE could reduce readmissions for low-risk patients and supplement care coordination for medium- and high-risk patients.Study DesignPragmatic, stepped-wedge cluster randomization trial with 5 implementation waves based upon primary care clinic region.MethodsAll inpatient hospital discharges between March 2020 and November 2020 were stratified by readmission risk. Low-risk patients were offered access to PDDE, and moderate-risk and high-risk patients were offered access to PDDE and care coordination. Readmission was defined as an unplanned inpatient admission within 30 days from discharge. An intention-to-treat primary analysis was conducted using mixed-effects logistic regression clustering for wave; a treatment-on-the-treated analysis was also conducted to assess the impact among program users.ResultsA total of 5490 patient discharges were examined (2735 control; 2755 intervention); 1949 patients were high risk, 2032 were medium risk, and 1509 were low risk. PDDE intervention did not significantly affect readmission among low-risk (95% CI, -0.23 to 0.90; P  = .23), medium-risk (95% CI, -0.14 to 0.60; P  = .21), and high-risk (95% CI, -0.32 to 0.64; P  = .48) groups after adjustment for time and patient factors. In a treatment-on-the-treated analysis, among patients who activated the PDDE program, readmission was also similar among the low-, medium-, and high-risk cohorts.ConclusionsOur study expanded resource-limited care coordination by offering low-risk patients a service they were unable to receive previously while having no impact on readmission. PDDE efficiently provided additional touch points between patients and providers.

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