Reducing Emergency Room Visits and
In-Hospitalizations by Implementing Best
Practice for Transitional Care Using
Innovative Technology and Big Data
Sharon Hewner, PhD RN • Suzanne S. Sullivan, PhD, MBA, RN, CHPN • Guan Yu, PhD
Background: Efforts to improve care transitions require coordination across the healthcare con-
tinuum and interventions that enhance communication between acute and community settings.
Aims: To improve post-discharge utilization value using technology to identify high-risk individ-
uals who might beneﬁt from rapid nurse outreach to assess social and behavioral determinants
of health with the goal of reducing inpatient and emergency department visits.
Methods: The project employed a before and after comparison of the intervention site with
similar primary care practice sites using population-level Medicaid claims data. The intervention
targeted discharged persons with preexisting chronic disease and delivered a care transition
alert to a nurse care coordinator for immediate telephonic outreach. The nurse assessed social
determinants of health and incorporated problems into the EHR to share across settings. The
project evaluated health outcomes and the value of nursing care on existing electronic claims data
to compare utilization in the years before and during the intervention using negative binomial
regression to account for rare events such as inpatient visits.
Results: Avoiding readmissions and emergency visits, and increasing timely outpatient visits
improved the individual’s experience of care and the work life of healthcare providers, while
reducing per capita costs (Quadruple Aim). In the intervention practice, the nurse care coordinator
demonstrated the value of nursing care by reducing inpatient (25%) and emergency (35%) visits,
and increasing outpatient visits (27%). The estimated value of avoided encounters over the secular
Medicaid trend was $664 per adult with chronic disease, generating $71,289 in revenue from
additional outpatient visits.
Linking Evidence to Action: Using health information exchange to deliver appropriate and timely
evidence-based clinical decision support in the form of care transition alerts and assessment of
social determinants of health, in conjunction with data science methods, demonstrates the value
of nursing care and resulted in achieving the Quadruple Aim.
Around the globe, healthcare systems are undergoing a tech-
nological revolution aided by unprecedented improvements in
computational capacity, storage, and speed, making it possible
to procure large datasets that may be used to improve patient
outcomes through the identiﬁcation of novel patterns, asso-
ciations, or trends from data that is collected during routine
patient care. These so-called “Big Data” are characterized by
their variety, velocity, veracity, and value (Brennan & Bakken,
2015). Moreover, these technological advances have given birth
to an exciting new ﬁeld of data-driven scientiﬁc inquiry known
as Data Science, an interdisciplinary approach that uses au-
tomated methods to extract actionable knowledge from large
datasets that may not have been apparent using traditional
methods of inquiry (Provost & Fawcett, 2013; Westra et al.,
2015). Nurses have been using data science approaches for
nearly a decade to discover knowledge, predict, and evaluate
patient outcomes (Westra et al., 2016).
Knowledge discovery, the product of data science inquiries,
strengthens the development of evidence-based care models
and clinical decision support (CDS) tools. When applied in
a practice setting, it becomes possible to streamline clinical
processes, while generating the data-driven evidence needed
to support and quantify the value of nursing care (Brennan &
Bakken, 2015; Pruinelli, Delaney, Garcia, Caspers, & Westra,
2016; Westra et al., 2015). Data science innovations provide
opportunities to analyze large datasets using modern meth-
ods that aim to improve healthcare quality, safety, and patient
outcomes. When harmonized, care delivery methods become
mutually beneﬁcial to the patient, health system, and provider;
Worldviews on Evidence-Based Nursing, 2018; 15:3, 170–177.
2018 The Authors. Worldviews on Evidence-Based Nursing published by Wiley Periodicals, Inc. on behalf of Sigma Theta Tau International The Honor Society of Nursing.
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