The long-term goal this 2-year study is to demonstrate the feasibility of using health information technology (HIT) to improve the quality of transitions from the hospital to primary care for the adult population with multiple chronic diseases by systematically improving two-way communication of critical information, resulting in fewer rehospitalizations and lower cost. The overall objective is to employ health outcomes analysis methodology developed at the population level on claims data to compare effectiveness of transitional care coordination after implementation of HIT interventions at the study and comparison primary care practices. Our central hypothesis is that patient-centered transitional care supported by integrated and interoperable health information will have better outcomes than usual care. The rationale that underlies the proposed research is that immediate notification regarding hospital discharges will enable timely, systematic, low-cost, telephonic outreach by nurse care coordinators in primary care to high risk patients. We plan to test our central hypothesis through the following specific aims: 1. Incorporate expanded COM- PLEXedex" algorithm and the Patient-Centered Assessment Model (PCAM) into the risk-adjusted care management model for Medicaid;2. Integrate health information exchange (HIE), risk stratification (COMPLEXe-dex"), and social complexity (PCAM) into the Care Transitions Dashboard;and 3. Measure HIT implementation's impact on practice workflow, care quality and health outcomes. This proposed mixed methods research identifies patients at high risk for readmission using the COMPLEXe-dex" hierarchical index of chronic disease complexity and links information from hospital admission, dis- charge and transfer records through the regional health information organization to the primary care electronic health record (EHR), to improve care coordinate on between the hospital and primary care. The health out- comes evaluation is based on the Medicaid-only roster of individuals, aged 18 - 64, in two primary care clinics, purposefully selected for meaningful use of the EHR and mix of patients. De-identified claims data for the prior 12 months will examine hospitalization rates, emergency room utilization, and outpatient visits for the entire population divided into complexity segments in the study and comparison sites. Comparison of health out- comes will be completed at baseline and at the end of the intervention year. Qualitative interviews will be con- ducted with staff at both sites to evaluate the impact on workflow. The quality of the care coordination process is evaluated through 90-day follow-up using chart review of cases that triggered a Care Transitions Dashboard. The impact of this innovative program is integration of population and patient-specific knowledge to target the large population of at-risk individuals with a timely, low-cost tht could prevent a costly hospitalization.
Coordinating transitions using HIT improves health outcomes for the large population with multiple-chronic disease through systematic, low-cost, informatics-supported, telephonic care coordinator outreach. Health outcomes are compared at two primary care clinics with differing levels of HIT integration and qualitative interviews and chart review evaluate process measures.