Innovative Information Technology-Powered Population Health Care Management Improves Outcomes and Reduces Hospital Readmissions and Emergency Department Visits.

BACKGROUND: Patients with chronic conditions are often the most frequent users of health care. Moreover, adapting to developments in one's illness, understanding how to self-manage a chronic illness, and sharing information between primary care and specialty providers, can be a full-time job for someone with a chronic illness. In response to these challenges, Christiana Care Health System (Wilmington, Delaware) developed Care Link, an information technology (IT)-enhanced care management support to enable populations of patients to achieve better clinical outcomes at lower cost.

METHODS: In 2012 Christiana Care received a grant to design a generalizable, scalable, and replicable IT-driven care model that would integrate disparate clinical and registry data generated from routine care to support longitudinal care management for patients with ischemic heart disease. The single-disease care management program was expanded beginning in mid-2015 to serve risk-based models for many diseases and chronic conditions.

RESULTS: More than 8,600 patients in several surgical and medical populations, including joint replacement, cervical spine surgery, and congestive heart failure, have been supported by Care Link. For example, preoperative assessment of patients with elective joint replacement to predict post-acute care needs led to an increase in the volume of patients discharged to home with self-care or with home health care by 30%-from 61% to 80%.

CONCLUSION: Care Link IT functions can be replicated to address the unique longitudinal care needs of any population. Care Link's next steps are to continue to increase the number of patients served throughout the region and to expand the scope of care management programming.