Improving Care Transitions for Complex Patients through Decision Support (North Carolina)

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Summary:

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.

Improving Care Transitions for Complex Patients through Decision Support - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs Through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017795
  • Project Period: 
    September 2008 – September 2012
  • AHRQ Funding Amount: 
    $1,198,254
  • PDF Version: 
    (PDF, 305.77 KB)

Summary: 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, their 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 care transition decision support. 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). Outcome measures included outpatient, emergency department, and hospitalization utilization rates. In addition, the economic impact of the intervention was measured relative to usual care.

Specific Aims:

  • Augment an existing HIE and CDSS by creating new functionality that can detect transitions in care and can conveniently communicate valuable, timely information regarding these care transitions to patients, their primary care clinicians, and members of multidisciplinary care management teams. (Achieved)
  • Implement the new functionality to improve the care of Medicaid beneficiaries with complex health care needs and evaluate the impact of the interventions in a three-arm randomized controlled trial. (Achieved)
  • Assess the economic impact of the new interventions at both a societal and an individual stakeholder level. (Achieved)
  • Disseminate information regarding the development and the impact of the interventions through Web teleconferences, professional meetings, educational lectures, peer review journals, and a promotional video. (Achieved)

2012 Activities: The 1-year randomized controlled trial (RCT) was completed in March 2012. Data collection, including patient, provider, and care manager surveys, as well as the chart audits to collect the clinical outcomes data, was completed in September 2012. Quality assurance activities and data analysis were completed, and manuscript development was in progress at the end of the year. In addition, the project team developed a video, Using IT to Fight Care Fragmentation, available at http://www.youtube.com/watch?v=bP4iRjCMsk8, describing the development and implementation of the intervention. Interviewees included Dr. David Lobach (the original principal investigator), a provider who used the reports, a care manager who received the alerts, and the project coordinator.

The project team used a 1-year no-cost extension to complete the RCT, which was delayed due to previous years’ delays in programming the interventions and subsequent analysis and manuscript preparation. As last reported in the AHRQ Research Reporting System, project progress was on track and budget spending was on target. This project was completed in September 2012.

Impact and Findings: 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 system is integrated into a regional HIE that permits the seamless integration of care transition information into the normal processes of the regional health network. 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, emergency department, or 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 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. Future studies in this area will need to pay particular attention to sociotechnical issues to enable better delivery of information interventions.

Target Population: Chronic Care*, Medicaid

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Improving Care Transitions for Complex Patients through Decision Support - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017795
  • Project Period: 
    September 2008 - September 2012
  • AHRQ Funding Amount: 
    $1,198,254
  • PDF Version: 
    (PDF, 204.62 KB)

Summary: 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 seeks 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 an open-source clinical decision support (CDS) application called ClinicaCDS 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 impact of the interventions are currently being 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). As a primary outcome measure, the research team used the overall rate of ED use. In addition, the economic impact of the intervention will be measured relative to usual care. Information-augmented care transitions between sites are expected to improve care coordination, quality, and appropriateness of care.

Specific Aims:

  • Enhance the existing HIE network and decision support tool. (Achieved)
  • Implement and evaluate the intervention. (Ongoing)
  • Conduct the economic attractiveness assessment. (Ongoing)
  • Disseminate the findings. (Ongoing)

2011 Activities: The CDS system and interventions were finished and tested in February 2011. The study went live in March 2011. Data collection is ongoing for the evaluation and will be complete when the randomized controlled trial (RCT) ends in March 2012. The focus going forward until the end of the study period will be to conduct the clinic site visits and continue to provide support for the project and the interventions. By the end of 2011, the 1-, 3-, and 6-month site visits were completed and the coordination team had begun initiation of the 9-month site visits. As part of these visits, the contextual evaluations are being conducted with clinic staff personnel as well as clinic care providers. This contact with the sites helps the project team to informally evaluate the system, hear the sites' concerns, and identify ways to increase the benefit of the interventions and decrease the information overload to sites. For example, the project team customized the sending of interventions (care event summaries and requests for information) based on the location (e.g., hospital of service) and type (e.g., ED, hospital, specialty encounters) of care event.

The research team continued telephone surveys of randomly-selected patients to confirm receipt of the letters and to ask whether they took the letters to their followup appointments with their primary care clinicians. They modified their patient contact protocol so that patients are called a week rather than a month after an event to lessen the impact of elapsed time on patient recall. Finally, the research team, with the assistance of clinicians, has continued to work on their patient education brochures, which will be completed in January 2012 after the required departmental and State Medicaid program review process.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track. The project budget funds are slightly underspent due to the conservation of funds to complete the RCT. The project team is using a 1-year no-cost extension to ensure adequate time for the RCT, which was delayed due to previous years' delays in programming the interventions and subsequent analysis and manuscript preparation. In addition, personnel change resulted in one of the co-investigators taking on the role of project principal investigator.

Preliminary Impact and Findings: Evaluation outcomes will not be available until the RCT is complete. However, during the site monitoring visits, clinics have reported that they are pleased with the intervention and feel the reports can be integrated into their workflow with minimal disruption.

Target Population: Chronic Care*, Medicaid

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Improving Care Transitions for Complex Patients through Decision Support - 2010

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS08-002: Ambulatory Safety and Quality Program: Improving Management of Individuals with Complex Healthcare Needs through Health Information Technology (MCP)
  • Grant Number: 
    R18 HS 017795
  • Project Period: 
    September 2008 – September 2011
  • AHRQ Funding Amount: 
    $1,198,254
  • PDF Version: 
    (PDF, 577.4 KB)


Target Population: Chronic Care*, Medicaid

Summary: The care of patients with complex health care needs is often fragmented because they receive care from multiple providers in disparate locations and because information related to this care is frequently not transmitted between providers or locations. Inadequate inter-provider communication and care coordination significantly lowers care quality and compromises patient safety. This project seeks 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 builds upon the Community-Oriented Approach to Coordinated Healthcare (COACH), an existing regional health information exchange (HIE) network that connects providers serving Medicaid beneficiaries in rural and urban North Carolina. It will also implement and utilize an open source clinical decision support (CDS) application called ClinicaCDS to detect care transitions, and produce and send care event summary reports to patients, patients’ assigned medical homes, and care managers. These intervention notices will support traditional clinic-based models of care as well as models that incorporate population health management and cross-disciplinary teams.

The impact of the interventions will be evaluated by randomizing patients by family unit with complex health care needs 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). The primary outcome measure is the overall rate of ED use. In addition, the economic impact of the intervention will be measured relative to usual care. Information-augmented care transitions between sites are expected to improve care coordination, quality, and appropriateness of care.

Specific Aims:
  • Enhance the existing HIE network and decision support tool. (Achieved)
  • Implement and evaluate the intervention. (Ongoing)
  • Conduct the economic attractiveness assessment. (Upcoming)
  • Disseminate the findings. (Upcoming)

2010 Activities: During 2010, the team made significant enhancements to the COACH HIE including completing the programming necessary for the importation of Admission/Discharge/Transfer (ADT) data feeds for the five participating hospitals. They are now receiving nightly ADT data files which will be used to generate notifications for care managers and primary care clinics regarding patient hospital discharges and ED encounters for Medicaid patients with complex care needs. In addition, the project team identified a method for identifying specialty encounter visits based on current procedural terminology (CPT)-4 evaluation and management codes, location of care delivery, and the specialty of the provider billing for a specialty care service in the Duke University Health System. They validated this method by conducting patient chart reviews.

The project team encountered delays during the year in programming the interventions into the Duke proprietary CDS system due to turnover of multiple staff and the learning curve associated with familiarizing programmers with the proprietary CDS. Therefore, the team decided to migrate to ClinicaCDS for this project with the hope that the application would be easier to develop, configure, implement, and maintain. The team was able to identify several modules that were part of the proprietary CDS system that could be reused in the new system. Upon completion of the specifications and requirements, the programmers “roughed out” all of the required components by creating prototypes of the interventions beginning from the detection of a care transition. This process allowed the team to demonstrate that all of the necessary components were functional by the end of October 2010. The software development effort during the months of November and December focused on refinement of these newly created rough components.

Because of a mandate by North Carolina Medicaid to reduce costs for hospitalizations and ED utilization, a second phase of the project was added. The network partners requested daily notices of hospital discharges and ED encounters from data in the COACH HIE. These requested notices are similar to the care manager-oriented interventions for the proposed study, although the care transition notices are driven from billing instead of ADT data. To accommodate this request, a new Phase 1, which provides care manager notices derived from existing claims data for operational needs on approximately 47,000 Medicaid beneficiaries, was implemented in December 2009. The 12 month randomized controlled trial (RCT), now called Phase 2, will provide the originally proposed study interventions for approximately 4,600 patients with complex health needs. The planned start for Phase 2 is expected to roll out in February 2011, pending the software migration and the programming of the interventions into ClinicaCDS.

During the year, the project team devoted considerable time to refining and finalizing the content for the four intervention documents: care event summary reports, patient letters, care event notices, and release of information requests. This process included completing the final focus group with patients to inform the content of the patient letters and the Health Education Brochures; defining the data elements and completing the data extraction for patient specialty care encounters for the care event summary reports and care event notices; working with the primary care sites to ensure that the content in the documents is appropriate; and submitting and receiving final approval from the State Medicaid office. In late 2010, the clinical research coordinator and the research assistant distributed materials and conducted onsite visits to introduce the project to the participating primary care clinics.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2010): Project progress is on track in some respects, but not others and project budget to date is significantly underspent, more than 20 percent. However, the project team made adjustments and there is a viable plan for meeting all project aims. Part of this delay was due to the mandate by North Carolina Medicaid while other delays involved the staffing retention and CDS migration described above.

Preliminary Impact and Findings: Evaluation outcomes will not be available until the RCT is complete.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions, and the electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

*AHRQ Priority Population

Improving Care Transitions for Complex Patients through Decision Support - Final Report

Citation:
Eisenstein E. Improving Care Transitions for Complex Patients through Decision Support - Final Report. (Prepared by Duke University under Grant No. R18 HS017795). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 629.08 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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