The Agency for Healthcare Research and Quality (AHRQ) has awarded the University at Buffalo School of Nursing a grant to create a pilot project whose goal is to work with primary care physician’s offices, their patients and families to see that patients get follow-up care very soon after leaving the hospital.
According to Sharon Hewner, Ph.D., R.N., assistant professor of nursing and author of the grant, there has been a lack of timely communication between the hospital and community setting. “Our project will use the electronic health record (EHR) to exchange health information across settings in real time and provide decision support to nurse care coordinators in primary care offices to proactively prevent re-hospitalization,” Hewner said in a news release.
As part of the study, Hewner said they will use a care transitions dashboard to incorporate an alert message about a hospital discharge from the regional health information organization, HEALTHeLINK, with information from the electronic health record at Elmwood Health Center in Buffalo.
The dashboard will aim to help guide the nurse care coordinator in developing an individualized plan of care specifically to prevent re-hospitalization through its structured assessment of social factors such as health literacy, home environment, and financial resource issues that may increase the complexity of care after leaving the hospital.
According to Hewner, most post-discharge intervention studies focus on a single disease, such as heart failure, and not a variety of chronic health problems or patients with a number of interdependent health issues. This study will try to improve the identification of patients who are at-risk for being readmitted by using the COMPLEXedex, a hierarchical algorithm which divides the population into healthy, at-risk, chronic and complex cohorts based on nine prevalent chronic conditions, she said.
Health outcomes such as readmissions and emergency department visits in the 90 days after discharge will be compared with another primary care practice using data from the New York State Medicaid Data Warehouse.
Hewner said the study design is significant because it promotes a low-cost, targeted intervention—a health are coordinator using telephone outreach to patients guided by an organized assessment—to ensure that the care is more patient-centered and takes into account that this may be a time when the patient is vulnerable and therefore likely to misinterpret instructions and be too preoccupied, or ill, to arrange follow-up with a primary care health provider on their own.
The grant is valued at $298,934 over a two-year period. The intended outcome of the study would be to develop an automated system, the care transitions dashboard, to notify the primary care practice of real-time discharge and for post-discharge follow-up to happen ideally with 72 hours of discharge, Hewner said.
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