Background: Patients in the United States suffer harm too often as they move between sites of health care, and their caregivers experience significant burden. Unfortunately, the usual approach to health care does not support continuity and coordination during such “care transitions” between hospitals, clinics, home or nursing homes. Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and emergency room visits.
Objectives: To identify which transitional care services and outcomes matter most to patients and caregivers, evaluate the comparative effectiveness of ongoing multi-component efforts at improving care transitions, and develop recommendations on best practices for the design, implementation and large-scale national spread of highly effective, patient-centered care transition programs.
Methods: We will use qualitative and quantitative methods, including site visits, surveys, and clinical and claims data to study historical, current, and future groups of patients, caregivers, and providers. The comparators will be hospitals and communities that have implemented different clusters of transitional care interventions. We will study diverse patient populations such as older adults, individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with special healthcare needs, including those with disabilities.
Patient-Centered Outcomes: Preliminary outcomes will include patient experience, patient reported health outcomes, patient utilization of health services (30-day emergency room visits, 30-day rehospitalizations), adverse drug events, and caregiver experience.
Patient and Stakeholder Engagement: This study combines the expertise of patients, caregivers, and stakeholders with national leaders in care transition research.
Anticipated Impact: This study will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which transitional care services are most effective and how best to implement them in the context of their own community.
Naylor MD, Shaid EC, Carpenter D, et al., Components of Comprehensive and Effective Transitional Care, Journal of the American Geriatrics Society (June 2017).
Hogan WR, Hanna J, Hicks A, et al., Therapeutic indications and other use-case-driven updates in the drug ontology: anti-malarials, anti-hypertensives, opioid analgesics, and a large term request, Journal of Biomedical Semantics (March 2017).
Shen E, Koyama SY, Huynh DN, et al., Association of a Dedicated Post-Hospital Discharge Follow-up Visit and 30-Day Readmission Risk in a Medicare Advantage Population, JAMA Internal Medicine (January 2017).
Li J, Brock J, Jack B, et al., Project ACHIEVE Team. Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness, BMC Health Services Research (February 2016).
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.