Coordinating Transitions: Health Information Technology Role in Improving Multiple Chronic Disease Outcomes

The transition of care from inpatient to outpatient settings is difficult, particularly for people who have multiple chronic diseases. Readmission within 30 days of discharge due to inadequate care coordination is costly, potentially unsafe, and wasteful. A lack of communication between providers in different care settings forces patients to relay information to providers, but relying on the recovering patient during the transition from hospital to primary care contributes to high readmission rates. Gaps in transitional care coordination for persons with chronic disease such as medication reconciliation, primary care follow up, and self-care knowledge, could be ameliorated with health informatics. Providing the right information to the right person at the right time to present the opportunity to intervene before there is a crisis facilitates effective transitional care coordination for patients.

This project evaluated the use of clinical decision support tools to improve the quality of transitions from hospital to primary care for adults with multiple chronic diseases. While researchers initially intended to develop a Care Transitions Dashboard within an electronic health record system, they instead elected to utilize HEALTHeLINK, an existing health information exchange (HIE), to allow for an interoperable solution for dissemination to primary care practices throughout the region. During the project, nurse care coordinators received transition alerts via secure email, prompting an outreach phone call to patients considered to be high-risk discharges, as identified by a hierarchical algorithm called COMPLEXedex™. During the call, the nurse assessed the impact of social and behavioral determinants of health and highlighted health concerns using a web-based version of the Patient Centered Assessment Method (PCAM). Finally, the nurses submitted a continuity of care document through HEALTHeLINK, to make information available to other providers.

The specific aims of the project were as follows:

• Improve risk-stratified care management model fit through customization of the clinical algorithm and the PCAM for Medicaid primary care. 
• Participate in interoperable HIE that integrates discharge information, risk stratification, and social factors to support telephonic care coordination. 
• Evaluate health information technology implementation’s impact on practice workflow, care quality, and health outcomes. 

This pragmatic clinical trial compared the intervention site and two control sites to the regional Medicaid population in the year before and during implementation to determine effectiveness of the intervention. They used COMPLEXedex™ to define the target population as adult Medicaid recipients with chronic disease, and counted inpatient (IP), emergency (ED), and outpatient (OP) visits using de-identified claims from the Medicaid Data Warehouse. Findings indicate that the project successfully modified practice workflow and implemented HIE through HEALTHeLINK. They also achieved a statistically significant 25 percent reduction in IP, 35 percent reduction in ED utilization, and 27 percent significant increase in OP visits that added revenue to the practice. The study also found higher value services utilization in the intervention site than in either control site or the regional Medicaid population.