Care coordination pilot looks to prevent hospital readmissions

The University of Buffalo is working to limit patient readmissions to hospitals and ERs via use of dashboard technology.

The Agency for Healthcare Research and Quality awarded the University at Buffalo School of Nursing a grant of $298,934 for the project--which will connect primary care physician's offices, their patients and families to ensure patients receive follow-up care after being released from the hospital, according to an announcement.

The study will incorporate a "Care Transitions Dashboard," Sharon Hewner, an assistant professor of nursing at Buffalo and author of the grant, said in the announcement.

Electronic health record information will be incorporated via the dashboard with alert messages on hospital discharges. That information will be used by nurse care coordinators to create individualized plans of care by assessing factors like health literacy of the patient, home environment and financial resource issues, according to the announcement.

The coordinator then will reach out to patients via telephone to ensure that care is patient-centered, Hewner said.

"We will also study how to implement a system of two-way communication, alerting the primary care clinic immediately about their patient's hospital discharge and transmitting the results of the back to the hospital and other providers," she said.

Other researchers are also using various technologies, including EHRs, to prevent readmissions.

An automated tool integrated into an EHR to predict patients at risk of hospital readmission is being studied by researchers at University of Pennsylvania School of Medicine, FierceEMR recently reported.

And last summer, El Camino Hospital in California reported reduced readmissions through the use of predictive analytics and videoconferencing with nursing home staff, according to a case study by the College of Healthcare Information Management Executives.

To learn more:
- read the announcement

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