CHIP Lecture: Improving Care Transitions for Complex Patients Through Decision Support

Suboptimal care transitions constitute a significant cause of morbidity, mortality, and excess health care costs in the United States. Since patients with chronic conditions and/or mental illnesses often require care from multiple care providers over disparate care settings, the negative consequences of fragmented care transitions are felt most acutely by these individuals.

When Apr 10, 2013
from 04:00 PM to 05:00 PM
Where Health Sciences Library room 328
Contact Name
Contact Phone 919-962-0182
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Because suboptimal care transitions frequently are associated with inadequate care coordination and ineffective communication among providers, patients, and their caregivers, the use of health information technology (HIT) has been identified as a promising strategy for improving the quality and safety of health care for patients with chronic health conditions.

A randomized trial was conducted of HIT-facilitated care transitions among Medicaid beneficiaries in six North Carolina counties. Patients were assigned to (1) usual care (n=2281), (2) clinical decision support (CDS) care transition messaging to patients and their medical homes (n=2240), or (3) CDS care transition messaging to patients, their medical homes, and their care managers (n=3482). This study sought to increase knowledge and understanding regarding the use of CDS for improving clinical and economic outcomes within a vulnerable population with chronic disease and/or mental illness; and to demonstrate a generalizable approach in a community setting that can be replicated at other sites.

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