Christian Tejeda, BS

Hospital discharge for patients with multiple chronic conditions (MCC) is challenging for hospital and primary care teams and patients who face difficulties with complex medication regimens, non-adherence post-discharge, and poor communication among care team members. These risks are especially important for people living with MCC, such as diabetes, congestive heart failure, and chronic kidney disease. Research supports the use of mobile apps for chronic disease patients, but there are none for MCC patients experiencing care transitions. This was a qualitative research study designed to utilize stakeholder interviews with providers and patient advisors to record key requirements for our Care Transitions App. Our research team developed an initial set of wireframes and two interview guides. The first author reviewed interview transcripts to identify key themes and developed an inductive set of codes. The transcripts were analyzed using Atlas.ti 9.1.3. We interviewed 23 providers and patient advisors and successfully identified 10 key themes: medication management, personal support network, health education, systematic communication, patients’ understanding of their chronic conditions, access barriers, motivational tools, disease management support, patient assessment, and self-management barriers. Our study contributes to the literature by identifying user needs for successful navigation of the care transition period by patients with MCC.