Informatics Models for the Health Management of Home Care Patients with Chronic Diseases

There is critical need for new care delivery models tailored to the needs of high risk patient populations to reduce healthcare utilization and improve health outcomes. This requires a deep quantitative understanding of the complex interactions between patients, diseases, and care delivery methods. This work will develop health informatics based analytical models that will help home care providers develop new services and technological innovations that better address the needs of low-income adults with high rates of chronic disease. The aims of this project are: 1) to identify prevalent chronic disease combinations and quantify the
effects of these diseases on hospital utilization in the Medicaid adult population, 2) to evaluate the impact of home health care services on patient outcomes in this population, and 3) to develop recommendations for services and innovations that will improve the effectiveness of home health care, reduce preventable hospitalizations, and improve patient health outcomes for this population. The key outcomes are: 1) detailed knowledge of the prevalence and impact of chronic disease on hospital utilization in the Medicaid adult population in home care, 2) new analytic methods for understanding the impact of chronic disease and home health care services on patient health outcomes (hospital utilizations), and 3) a framework for translating this knowledge into new and effective care models. This research builds upon on-going efforts in the Department of Industrial & Systems Engineering and the School of Nursing. Findings from this study will form the foundation for future extramural funding
proposals that will be submitted in 2016-2017.