PCORI has identified transitional care services as an important research topic. Transitional care services help patients as they move from the hospital to their home or another care facility. During this time, patients are at risk for health complications, poor recovery, or even a return to the hospital. Patients, clinicians, and others want to learn: What groups of transitional care services meet patients’ needs as they move from hospitals to other care settings? To help answer this question, PCORI launched a funding initiative in 2014 on The Effectiveness of Transitional Care. PCORI awarded this research project under this targeted initiative.
This research project is in progress. PCORI will post its findings here within 90 days after our final review is complete. In the meantime, results have been published in peer-reviewed journals, as listed below.
What is the research about?
Patients in the United States experience harm too often as they move between healthcare sites, such as hospitals or nursing homes. When healthcare providers don’t manage care transitions well, patients may experience emotional distress, side effects from medication changes, or worsening symptoms. One facility might lose test results or orders for new tests that come from another facility. Sometimes, patients may even have to go back to the emergency room or stay in the hospital again. These problems affect caregivers as well as patients. This study is identifying the transitional care services that matter most to patients and caregivers and are most helpful in ensuring a safe transition from one site to another.
Who can this research help?
This study will provide information to help hospitals, community-based organizations, patients, caregivers, clinicians, and others choose the most effective transitional care services and develop a plan for placing those services in their own communities.
What is the research team doing?
The study has two parts. First, the research team is doing group interviews with patients, caregivers, and doctors in more than 40 healthcare systems around the country that are trying to improve care transitions. The research team is also visiting these healthcare systems. The goal is to figure out which transitional care services, as well as what results from these services, matter most to patients and caregivers.
In the second part, the researchers are using surveys to identify the transitional care services that hospitals have put in place. They are looking at this information along with the information they are gathering from the in-person visits to the hospitals to find out which services work best for improving care transitions.
The research team is including patients and caregivers, in addition to experts in transitional care research, in designing and conducting the study. An advisory group that includes patients, caregivers, and advocacy groups is guiding the project.
Research methods at a glance
|Study Design||Prospective and retrospective cohort study|
|Population||Individuals who have Medicare fee-for-service insurance with a focus on diverse patient populations such as older adults, individuals with multiple chronic diseases, patients with mental health problems, patients who are covered by Medicare and Medicaid, patients with low health literacy/numeracy, people with limited English proficiency, people in racial and ethnic minority groups, individuals in low-income groups, residents of rural areas, and individuals with special healthcare needs, including those with disabilities|
Primary: patient readmission to hospital within 1 month of discharge from hospital, patient visit to emergency department within 1 month of hospital discharge
Secondary: patient experience of care, patient reports of health results, adverse drug events, and caregiver experience
|1-month follow-up after hospital discharge for primary outcomes|
|Article Highlight: The first phase of Project ACHIEVE, published in the Annals of Family Medicine, determined that patients and their caregivers facing a transition from a hospital to their home most want to feel prepared and capable of applying care plans, to receive unambiguous accountability from the healthcare system, and to feel that medical providers care for and about them.|
In Care Transitions, a Chance to Make or Break Patients' Recovery
A narrative on what happens when patients are harmed by poorly executed transitions between healthcare settings.
Other Health Services Interventions
Training and Education Interventions
Low Health Literacy/Numeracy
Individuals with Disabilities
Individuals with Multiple Chronic/co-morbid Conditions