Community project funding/congressionally directed spending - non-construction - the increasing population of high-need individuals is a significant and growing challenge for the nation

A significant proportion of these high-need individuals with multiple chronic or major complex chronic conditions reside in skilled nursing facilities, home health agencies, or hospice/palliative care facilities. The complex needs of these individuals requires robust availability of key clinical information to support the highest quality of care. This information is especially critical during times of transition, such as between homes with services (skilled nursing facilities, home health agencies, and hospice/palliative care) and hospitals. This quality improvement initiative is focused on developing a digital framework to support availability of critical information during periods of transition, with a particular focus on transitions of individuals between skilled nursing facility (SNF) and hospital sites in rhode island. The long-term goal of this project is to benefit high-need individuals with complex conditions during times of transition. To quantify the impact of this project in achieving this goal, a SNF quality and impact dashboard will be developed that will include measurable benchmarks, including: (1) number and rate of hospital readmissions; and and (2) number of complications and errors. IT is expected that the success of this project will have myriad benefits, including: (1) improvement of both patient and caregiver satisfaction; (2) improvement of clinician satisfaction; and (3) improvement of workflow efficiencies that support safe return to home. This project will expand the existing healthcare interoperability infrastructure in rhode island to support the high-need individuals and serve as a model for how public health infrastructure can significantly improve quality of care, improve patient satisfaction, and reduce healthcare expenditures. The focus of this one-year project will be to develop a sustainable approach to support availability of key clinical information (e.g., medication history) during transitions of care for SNF residents.