The Agency for Healthcare Research and Quality has awarded a grant to the State University of New York at Buffalo’s School of Nursing to create a pilot project designed to work with primary care physician’s offices, their patients, and families to see that patients get follow-up care soon after leaving the hospital.

“Our project will use the electronic health record 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," said grant coordinator Sharon Hewner.

As part of the study, Hewner says they will use a care transition 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, a community health center in Buffalo.

The dashboard will 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.

Hewner said the study design is significant because it promotes a low-cost, targeted intervention--a healthcare 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 intended outcome of the study is 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. The grant is valued at $298,934 over a two-year period.

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