Heather J. Sobko, PhD, RN, APRN, CRRP is a specialist in the development of innovative tools that support patient engagement for improvement in quality of care and patient outcomes. Dr. Sobko completed her doctoral studies in Nursing and Informatics at the University of Alabama at Birmingham and also has degrees in Psychology and Sociology. She completed a two-year National Research Service Award (NRSA) Post-doctoral Fellowship in Comparative Effective Research and is also a nationally certified readmission reduction fellow. She has published numerous papers and serves as a reviewer for several peer-reviewed journals.


Chronic diseases - such as heart disease, diabetes, COPD, arthritis and asthma – are among the most common, costly and preventable health problems in the U.S. Innovative technological “tools of engagement” can effectively address intransigent inefficiencies in healthcare delivery including uneven distribution of quality, escalating costs and adverse lifestyles that tend to exacerbate these problems. A large and growing segment of the population suffers from chronic diseases and can benefit from improved spatial-temporal access to health resources that promote engagement via information and communication technologies designed to connect patients with health care providers. These strategies are particularly effective during transitions of care, a time of well-documented increased risks known to lead to ED visits and hospital readmissions. We implemented a comprehensive Care Transition System designed to support both patients and providers. The system gathers clinically relevant information from patients and automatically triages needs to promote efficacious, cost effective clinical workflow. The system calls out to patients throughout the thirty day time period following hospital discharge and assesses the need for support along four clinical domains: signs and symptoms, medication management, follow-up care and health behaviors. Patients respond using their telephone – an inexpensive, readily accessible tool requiring no special training or equipment. Clinicians receive information in real time through a web-based, nurse-designed dashboard where they complete clinical documentation and generate progress notes that can be securely shared with external providers and EHRs. Use of the system demonstrated an 86% patient response rate with a 23% reduction in ED visits and hospital readmissions.