The care of patients with complex healthcare needs is often fragmented because they receive care from multiple providers across disparate care locations and because information related to this care is frequently not transmitted between providers or locations. Inadequate inter-provider communication and care coordination significantly lessen care quality and compromise patient safety. This three-year project seeks to improve outcomes, quality and coordination of care for patients with complex healthcare needs by facilitating the availability of information following three types of care transitions into the ambulatory care setting. Specifically, information regarding care transitions will be made available to patients, primary care practitioners and care managers following hospitalizations, emergency department (ED) encounters, and specialty clinic evaluations. This project will build upon a regional Health Information Exchange (HIE) network created to connect providers serving 42,000 Medicaid beneficiaries across traditional institutional boundaries from both rural and urban settings in a 6 county region in the Northern Piedmont of North Carolina. This network includes 25 ambulatory care practices, 3 federally qualified health centers, 4 rural health clinics, 3 urgent care facilities, 11 government agencies, 5 hospitals and 2 cross-disciplinary care-management teams. Within this HIE network, 4,608 patients with complex healthcare needs have been identified. For this project, a standards-based clinical decision support tool will be utilized in order to ensure that the proposed approach is generalizable, portable, and scalable, and routinely available claims and scheduling data will be used as the primary data source. This approach will support both traditional clinic-based models of care as well as new care models including population health management and the use of cross-disciplinary teams.
Under Aim 1, the existing HIE network and decision support tool will be enhanced to enable detection of transitions in care and delivery of timely, patient-specific information regarding these care transitions to patients, primary care clinicians and multidisciplinary care management team members.
Under Aim 2, the impact of the proposed approach will be evaluated in a randomized controlled trial involving approximately 4600 patients, 309 primary care clinicians, and 31 care management workers. Patients with complex healthcare needs will be randomly assigned by family unit to one of three groups: 1) information on care transitions sent to patients and their clinic-based caregivers;2) information sent to patients, their clinic-based caregivers and their care managers;and 3) no information sent. The primary outcome measure will be the overall rate of ED utilization for each study group.
Under Aim 3, the economic attractiveness of the proposed approach will be determined.
Under Aim 4, the technology and results of this study will be disseminated through public media, publications and presentations. Information-augmented care transitions between sites should result in improved care coordination, higher quality of care, and more appropriate care.
In addition, in two or three sentences, describe in plain, lay language the relevance of this research to public health. If the application is funded, this description, as is, will become public information. Therefore, do not include proprietary/confidential information. This project seeks to develop and evaluate a decision support system that will augment the availability of information at ambulatory care practices following three types of care transitions (hospital discharges, emergency department encounters and specialty care evaluations). The system will detect a care transition and then send information about the detected care event to patients, ambulatory care providers and care managers, thus, supporting both traditional clinic-based models of care and new care models including population health management and cross-disciplinary teams. The proposed system will be based on an emerging standard for decision support and will utilize routinely available claims and scheduling data in order to serve as a replicable model for broader use of decision support for handling care transitions. Increased availability of information around care transitions can be expected to improve healthcare quality and safety at an acceptable cost, and augment disease management for patients and populations.
