: Patients with chronic illness are at risk for complications and unnecessary disease exacerbations from a lack of coordination and quality in an already fragmented health care system. Many models of care management, like Care Management Plus (CMP), have been successful in improving health outcomes through clinical redesign using health information technology (HIT). To improve care for patients with complex needs these models use population management, patient-centered goals, quality measures, and clinical reminders. There are three objectives for proposed study. 1) To understand if an integrated care coordination information system (ICCIS) can be created in a diverse set of clinics using certified EHRs and existing standards. 2) To assess if the functions in the ICCIS system can be used by the clinics. 3) To evaluate if these system changes lead to improved patient outcomes. First, the research team will assess existing HIT capabilities of participating sites. Based on the initial assessment ICCIS will be implemented to see if HIT use in care of patients with complex healthcare needs is possible. Next, the implementation process and its perceived benefits will be assessed using the Glasgow REAIM model.
RE AIM i s designed for measuring success at individual, programmatic, organizational, and policy levels. A randomized controlled trial will examine whether six participating clinics can use HIT to monitor and deliver care for high risk patients with a care coordination model (arm 1) or quality performance model (arm 2). Two outcome measures will be examined. 1) Change in utilization - hospitalizations and ED visits and 2) Patient satisfaction at the clinic level. Utilization will be examined by comparing hospitalization rates and ED visits before and after implementation using billing data. Patient satisfaction will be assessed by surveying a random sample of 1200 patients pre- and post-intervention. Research personnel will administer the ACAHPS survey with specific additional questions about transitions of care and care coordination.

Public Health Relevance

Care coordination and quality improvement models like those tested in this study respond to a current gap in the organization and delivery of evidence-based care for the growing population of chronically ill in the United States. We are studying models of care that are both very similar to and connect with core concepts of public health system's organization and delivery of services. These core concepts include a focus on community and patient-centered participation, preparing the public health workforce, and supporting organizational capacity to provide the needed healthcare services.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Research Demonstration and Dissemination Projects (R18)
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Special Emphasis Panel (ZHS1-HSR-A (01))
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Bernstein, Steve
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Oregon Health and Science University
Biostatistics & Other Math Sci
Schools of Medicine
United States
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