Project Details - Ended
- Grant Number:R18 HS017795
- Funding Mechanism:
- AHRQ Funded Amount:$1,123,509
- Principal Investigator:
- Project Dates:9/30/2008 to 9/29/2012
- Care Setting:
- Medical Condition:
- Health Care Theme:
The care of patients with complex health care needs is often fragmented because patients receive care from multiple providers in disparate locations and because information related to this care is often not transmitted between providers or locations. Inadequate inter-provider communication and care coordination significantly lowers care quality and compromises patient safety. This project sought to improve outcomes, quality, and coordination of care for patients with complex health care needs by facilitating the availability of information following three types of care transitions into ambulatory care: hospital discharge, emergency department (ED) discharge, and specialty care referrals.
The project built upon the Community-Oriented Approach to Coordinated Healthcare, an existing regional health information exchange (HIE) network that connects providers serving Medicaid beneficiaries in rural and urban North Carolina. The project team implemented a Web-based service clinical decision support system (CDSS) application called CFM-CDSS to detect care transitions, and produce and send care event summary reports to patients, patients’ assigned medical homes, and care managers. These intervention notices support traditional clinic-based models of care, as well as models that incorporate population health management and cross-disciplinary teams. The system was based on HL7 standards for decision support, and utilized routinely available claims and scheduling data in order to serve as a replicable model for broader use of decision support for handling care transitions. When the decision support system detected a care transition, four information interventions could be created: 1) care event summary reports faxed or emailed to the patient’s medical home; 2) patient letters containing information similar to that in the care event summaries with reminders of scheduled appointments and health education material as appropriate; 3) release of information requests sent to the health information management department of the care encounter site on behalf of the patient’s medical home; and 4) care event notices regarding the care encounters that were emailed to the patient’s assigned care manager.
The impacts of the interventions were evaluated by randomizing patients with complex health care needs by family unit into one of three arms: 1) information on care transitions is sent to patients and clinic-based caregivers; 2) information on care transitions is sent to patients, clinic-based caregivers, and care managers; and 3) no information is sent (i.e., usual care). Outcomes measures included outpatient, ED, and hospitalization utilization rates. In addition, the economic impact of the intervention was measured relative to usual care.
The decision support system was able to detect care transitions for this study’s complex patients and provide relevant information to ambulatory care practices, patients, and care managers. In addition, the system was able to increase the number of care manager contacts for patients in the third study group versus the control group.
The successful implementation of the study interventions demonstrates that the management of health care for a population is feasible through a regional HIE primarily populated with Medicaid patients. However, there were no differences in outpatient, ED, and hospitalization encounters among the three study groups. Although the letters to patients and email notices to care managers were delivered successfully, the site audits found that only 60 percent of the information directed to patient providers was available and in patient charts when followup visits for complex patients occurred. Hence, the most important information for managing care transitions was frequently missing and not available to the medical home providers for consideration in their decisionmaking. Despite the fact that the project team performed workflow analyses for each study site, it appears that the integration of new information into existing workflows remained a problem for a significant number of study sites. The project team believes that future studies in this area will need to pay particular attention to sociotechnical issues to enable better delivery of information interventions.