Identifying Patients with High Need During Care Transitions to Improve Care and Meet Social Needs


Engaging and Empowering Patients


Improving Care During Patient Transitions

Using health information exchange to identify high-need patients during care transitions can facilitate cross-sector communication, improve care continuity, and reduce rehospitalizations and other acute care.

Using health information exchange to support transitions in care

People with multiple complex chronic conditions, functional disabilities, and/or social needs often need highly coordinated, cross-sector care and support when discharged from the hospital. For example, individuals with housing insecurity may not only require followup care from medical and behavioral health providers but may also need access to social services at the time of discharge from the hospital. This fragmented continuum of care can add to treatment burden and jeopardize the safety of individuals who already have compromised health. In a previous AHRQ-funded study, Dr. Sharon Hewner and her team at the State University of New York at Buffalo developed and implemented the coordinating transitions intervention (CTI) that used health information exchange (HIE) data to alert primary care providers of high-risk patients’ discharge from the hospital and provide rapid nurse outreach to assess social and behavioral determinants of health.

Identifying high-need and high-risk patients to support cross-sector care: enhanced CTI

While the research showed that CTI decreased rehospitalizations and emergency department (ED) visits, Dr. Hewner and her team saw a persistent gap in primary care followup, social needs assessment, and collaborative cross-sector care planning for post-discharge patients most in need of support and at risk of rehospitalization. In this followup research, the team is now expanding CTI to better pinpoint patients needing intensive care transition followup using algorithms and risk stratification and to engage social and behavioral health providers in managing them, including developing crosssector comprehensive shared care plans. The enhanced CTI will send providers real-time discharge alerts generated by a robust algorithm that identifies patients the most in need of cross-sector care. The personalized alert will trigger the creation of a comprehensive shared care plan curated by a professional care manager and shared with healthcare, behavioral health, and social service providers using HIE.

“It’s not just health problems, it’s people who also have behavioral health problems and probably various unmet social needs that we’re trying to figure out. How do we quickly give the right people the right information so they can take an immediate action to prevent someone from really running into problems once they are home?”
- Dr. Sharon Hewner

Focusing on high-risk and high-need patients should improve continuity and reduce unnecessary care

The research team will study the effect of the enhanced CTI on the care coordination process, patient and provider burdens of care, and healthcare use. The hope is that expanding CTI will better support the identification of complex patients at the point of transition between care settings, enhance communication through a shareable comprehensive care plan, and facilitate referrals to care management, thereby improving continuity and reducing rehospitalization and other acute care visits.