Abstract:
Coordinating transitional care for high-need/high-cost patients (HNHC); those with multiple chronic or complex
chronic conditions, functional disabilities and/or social needs; often requires collaboration with service partners
outside the health care sector. To improve care for HNHC patients, there is a critical need to: narrow the
population receiving intensive care transitions follow-up to those with the greatest need, partner with social
sector providers to improve transitional care continuity, and maximize health information technology, such as
health information exchange (HIE), to include cross-sector comprehensive shared care plans (CSCP). Our
long-term goal is to coordinate care for HNHC patients as they transition between settings to reduce low-value
utilization, improve continuity and equity, and reduce burden, while improving safety through better adherence
to treatment plans and avoided readmission. The success of our R21 Coordinating Transitions Intervention
(CTI) demonstrates the potential of HIE to support quality improvement, thereby providing a unique opportunity
to expand and refine the intervention to meet the needs of this vulnerable HNHC population. The objective of
this project is to improve the evidence-based Coordinating Transitions Intervention (CTI) to include cross-
sector continuity, risk stratification, social needs assessment, and shared care planning for HNHC patients that
can then be hardwired into HIE and used as a collaborative tool across settings. Identifying HNHC patients at
the point of transition between care settings, coupled with enhanced communication through an interoperable
shared care plan, will facilitate referrals to care management, improve continuity, and reduce reliance on low-
value care. The specific aims are to:
1) expand the scope of the R21 to include the social and behavioral health sectors as equal partners in
managing HNHC patients during care transitions, and implement the project at remote practice sites;
2) further develop the CTI 's HIE capability to segment the HNHC population into subsets with specific cross-
sector needs and expand knowledge transfer between health and social sectors (care alerts and CSCP); and
3) evaluate the impact of Personalized Cross-sector Transitional Care Management (PC-TCM) using HIE on
patient burden, care team empowerment and collaboration, and utilization value. The expected outcomes are
real-time discharge alerts that will be sent to regional providers generated by a robust algorithm that accurately
identifies segments of HNHC population in need of cross-sector care. The personalized alert will trigger the
creation of a comprehensive care plan (CSCP) curated by a professional care manager, that includes both
social and healthcare sectors, and is shared across health and social service providers using HIE. As the
intervention is implemented in primary care and behavioral health settings, we will measure the care
coordination process and outcomes, patient and provider burdens of care, and utilization.
