Project 463054

To improve outcomes for individuals with acquired brain injury (stroke and traumatic brain injury), healthcare settings are reorganizing care around the patient and providing the full cycle of care that encompasses inpatient, outpatient and rehabilitative care with continuous patient education and engagement and follow-up. For this integrated care approach to work, patients, clinicians and decision-makers need access to information to make optimal decisions during every step of the care process. This includes decisions at the person level about where to transition a patient based on their needs, and how to personalize interventions and rehabilitation care, and coordinate care between care providers and the person's family. At the program level, access to the right information can inform decisions about which services are working and where adjustments are needed. Currently, decisions regarding care trajectories are substantially inhibited by delayed evaluation and access to data along the care trajectory. Digital health solutions have the potential to transform how care is provided by providing timely access to data. This study will evaluate a digital health solution that will i) be used to measure outcomes that matter to patients and caregivers, clinicians, and decision- makers; ii) to coordinate patients' care; iii) improve communication between care providers; iv) guide the development of a personalized care plan for patients; v) and provide educational and self-management modules to empower patients to be actively involved and self-manage their health. We will work closely with patient and health system partners to evaluate the digital solution by measuring patient and clinician experience, and outcomes before and after the digital solution is used. The results of this study will provide needed evidence to support how and if digital health can improve patient-centered care and outcomes.