People Inc.’s Elmwood Health Center has been selected to play a major role in a federally-funded study project that may eventually change how patients are treated following their discharge from the hospital.

The Center will participate with the University at Buffalo School of Nursing as the lead entity and HEALTHeLINK, the regional health information organization, in the pilot project funded through a two-year, $298,000 grant from the U.S. Agency for Healthcare Research and Quality (AHRQ).

Called the Care Transition Project, its goal is to work with primary care physician offices, their patients and families to see that patients receive follow-up care very soon after leaving the hospital.

Hospital readmissions is an area of increasing healthcare financial focus. Medicare alone spends an estimated $15 billion annually on readmissions, which occur after 30 days of discharge most frequently with older patients and especially those with a chronic disease.

“Experts believe that one way to prevent a return to the hospital or emergency room is through better communication to patients and their physicians about follow-up care,” said Associate Vice President, People Inc./Director, Elmwood Health Center, Frank Azzarelli.

As part of the study, the Elmwood Health Center will serve as the project’s only community-based health center. The Center will participate in the timely exchange of electronic health information to support nurse care coordinators in primary care offices in making proactive decisions that will prevent the readmission of patients to hospitals.

An important component of the project, a Care Transition Dashboard, will be developed to incorporate an alert message about a hospital discharge from HEALTHeLINK with information from Elmwood Health Center’s electronic medical record on that specific patient.

“This will enable discharged patients to be connected with, and seen by, their primary care provider in a much more timely manner, thus reducing readmission rates and subsequently overall hospital costs,” Azzarelli said.

“Ultimately, once the dashboard and care coordination processes are developed, this approach can be replicated in many primary care locations across the country,” he said.