Published May 10, 2021
A $1.95 million federal grant will support a UB nursing professor’s research into finding better care management and coordination of high-need/high-cost patients transitioning from hospitals into the community.
Principal investigator of the grant is Sharon Hewner, associate professor in the School of Nursing, who will administer the five-year grant from the Agency for Healthcare Research and Quality, the lead federal agency charged with improving the safety and quality of America’s health care system.
The grant targets patients considered high needs/high cost, or HNHC patients, those considered in the top 5% of medical expense.
“Care transitions between the hospital and the community for socially, medically and behaviorally complex persons often result in rapid readmission to the inpatient or emergency department setting,” says Hewner.
“Care transitions for this complex population require coordination of services from the social, behavioral health and health sectors.”
Hewner’s project will provide just that kind of trained coordination of services. The study will satisfy the need for a “reliable way to support cross-sector collaboration,” Hewner says, by developing what she describes as “evidence-based health information exchange pathways and applying them to shared care alerts and care plans between the health and social sectors.”
“Right now, there is no reliable way to support cross-sector collaboration,” she explains. “However the project will adapt evidence-based health information exchange pathways and apply them to shared care alerts and care plans between the health and social sectors.”
Coordination of transitional care for HNHC patients often requires the close collaboration of those providing services outside the health care section, according to Yu-Ping Chang, associate dean for research and scholarship in the School of Nursing. “This is especially true for those with multiple chronic or complex chronic conditions, functional disabilities and/or social needs.”
“The objective of this project,” Chang says, “is to improve the evidence-based coordinating transitions intervention to include cross-sector continuity, risk stratification and social needs assessment, and shared care planning for HNHC patients that can then be hardwired into health information exchange and transmitted across settings.”
Hewner says her background in medical anthropology allowed her to examine how households use their knowledge and resources to maintain the health of family members. That led to consideration of the impact of social determinants of health, and the role that social risk factors play in post-discharge recovery, she says.
“On the health care delivery side, the project will use the alerts to create a team of social and health providers who are able to meet the specific needs of the individual,” Hewner says. “The team will develop a comprehensive shared care plan that is aligned with the patient’s goals for care and lead to improved continuity for these complex patients.”
Clinical partners in the project include HEALTHeLINK, the Western New York Clinical Information Exchange, Buffalo City Mission, Jericho Road Community Health Center, and Spectrum Health and Human Services. The new Buffalo City Mission currently has on-site clinics for primary care (Jericho Road) and behavioral health services (Spectrum).
UB co-investigators include Suzanne Sullivan, School of Nursing; Elizabeth Bowen, School of Social Work; Varun Chandola, Department of Computer Science and Engineering; Ekaterina Noyes, School of Public Health and Health Professions; and Guan Yu, Department of Biostatistics.