Transitional Care Projects by Patient Population
General Population
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
- Can a Patient-Centered Approach to Preparing Patients for Kidney Failure Improve Patient Outcomes?
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED -- The GUIDED HF Study
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
- Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
- A Patient-Centered Approach To Successful Community Transition After Catastrophic Injury
- Improving Measurement Of Health Care Transitions through Key Stakeholders’ Eyes
- Improving Care Transitions For Acute Stroke Patients Through A Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Helping Patients with Mental Illness Engage in Their Transitional Care
- Does Care Management Help Patients Recover from a Serious Injury?
- Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury
- Comparing Two Ways to Provide Palliative Care to Older Adults with Serious Illness
- A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
- Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
- Comparative Effectiveness Trial of Perioperative Telemonitoring for Functional Recovery and Symptoms
Low Socioeconomic Status
Medicare Beneficiaries
- Comparing Recovery Options for Stroke Patients
- An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
- Identifying Which Transitional Care Services Matter Most to Patients and Caregivers -- The ACHIEVE Study
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
Pediatric and Young Adults
- Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
- Improving Post-Discharge Outcomes By Facilitating Family-Centered Transitions From Hospital To Home
- Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
- Comparative Effectiveness of Peer Mentoring versus Structured Education-Based Transition Programming for the Management of Care Transitions in Emerging Adults with Sickle Cell Disease
- Comparative Effectiveness of Direct Admission & Admission through Emergency Departments for Children
- Improving Family-Centered Pediatric Trauma Care -- The Standard of Care versus the Virtual Pediatric Trauma Center
Rural
- Rural Options At Discharge Model of Active Planning -- The ROADMAP Study
- Improving Family-Centered Pediatric Trauma Care -- The Standard of Care versus the Virtual Pediatric Trauma Center