The Transitional Care Evidence to Action Network (TC-E2AN) sought to facilitate collaboration and share lessons learned about conducting patient-centered research in transitional care.
The 30 projects composing the TC-E2AN have been comparing which approaches work best to reduce readmissions and improve patient experience and a wide range of outcomes important to patients and other healthcare stakeholders. The overarching goal of the network has been to cultivate a body of evidence on transitional care that is actionable and relevant to patients, families, clinicians, healthcare delivery systems, and payers.
These projects are located across 16 states and the District of Columbia.
Locations of Projects in the Transitional Care Evidence to Action Network
Locations of Projects in the Transitional Care Evidence to Action Network
The yellow points indicate locations of TC-E2AN investigators; shaded states indicate project locations.
Using webinars, in-person meetings, collaborative projects, and other approaches, TC-E2AN is designed to:
- Facilitate engagement and collaboration among PCORI awardees studying transitional care to enhance work in progress and assure that work is relevant to key stakeholders and end users.
- Engage awardee teams and facilitate cross-learning between them.
- Link awardees with end users to enhance relevance of evidence and increase the likelihood of uptake of findings.
Learn more about each of the projects under the TC-E2AN
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
Hanan J. Aboumatar, MD, MPH | Johns Hopkins University | Study Location: Maryland - Comparing Recovery Options for Stroke Patients
Janet Prvu Bettger, ScD | Duke University | Study Location: Nationwide - Can a Patient-Centered Approach to Preparing Patients for Kidney Failure Improve Patient Outcomes?
Leigh E. Boulware, MD, MPH | Duke University | Study Location: Pennsylvania - Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions -- The RISE Study
Adam Brooks, PhD | Treatment Research Institute, Inc. | Study Location: Pennsylvania - An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
Donna Lynne Carden, MD | University of Florida | Study Location: Florida - GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED -- The GUIDED HF Study
Sean Collins, MD | Vanderbilt University | Study Location: Indiana, Michigan, New York, Tennessee - Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
Kyaien Conner, PhD, MPH, LSW | University of South Florida | Study Location: Florida - Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
Benjamin G. Druss, MD, MPH | Emory University | Study Location: South Carolina - Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
Pamela W. Duncan, PhD, PT | Wake Forest University Health Sciences | Study Location: North Carolina - Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
Karen Fratantoni, MD, MPH | Children's National Medical Center | Study Location: District of Columbia - Comparing Two Ways to Provide Palliative Care to Older Adults with Serious Illness
Corita R. Grudzen, MD, MS | New York University School of Medicine | Study Location: New York, Massachusetts, Michigan, Ohio, Florida, Connecticut - Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury -- The BRITE Study
Jeanne Hoffman, PhD | University of Washington | Study Location: Washington - A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury
Michael Jones, PhD | Shepherd Center | Study Location: Georgia - Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
Rainu Kaushal, MD, MPH and Ruth Masterson Creber, PhD | Weill Cornell Medicine | Study Location: New York - Improving Measurement of Health Care Transitions through Key Stakeholders’ Eyes
Catarina Kiefe, MD, PhD | University of Massachusetts Medical School Worcester | Study Location: Massachusetts - PATient Navigator to rEduce Readmissions -- The PArTNER Study
Jerry Krishnan, MD, PhD | University of Illinois at Chicago | Study Location: Illinois - Comparative Effectiveness of Direct Admission & Admission through Emergency Departments for Children
JoAnna Leyenaar, MD, MPH, MS | Dartmouth-Hitchcock Clinic | Study Location: New Hampshire - Improving Family-Centered Pediatric Trauma Care -- The Standard of Care versus the Virtual Pediatric Trauma Center
James P. Marcin, MD, MPH | UC Davis | Study Location: California - Comparative Effectiveness of Peer Mentoring versus Structured Education-Based Transition Programming for the Management of Care Transitions in Emerging Adults with Sickle Cell Disease
Ifeyinwa Osunkwo, MD, MPH | Carolinas Medical Center | Study Location: North Carolina, South Carolina, Georgia, Kentucky, Alabama, Mississippi, Virginia - Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program -- The MISST Study
Mathew John Reeves, DVM, PhD | Michigan State University | Study Location: Michigan - Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
David M. Rubin, MD, MS | The Childrens’ Hospital of Philadelphia | Study Location: Pennsylvania, Ohio - Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
Jeffrey L. Schnipper, MD, MPH | Brigham and Women's Hospital | Study Location: Massachusetts - Rural Options At Discharge Model of Active Planning -- The ROADMAP Study
Tom Seekins, PhD | University of Montana | Study Location: Montana - Improving Post-Discharge Outcomes by Facilitating Family-Centered Transitions from Hospital to Home -- The H2O Study
Samir S. Shah, MD, MS | Cincinnati Children's Hospital Medical Center | Study Location: Ohio - Comparative Effectiveness Trial of Perioperative Telemonitoring for Functional Recovery and Symptoms
Virginia Sun, PhD, RN | City of Hope | Study Location: California - Helping Patients with Mental Illness Engage in Their Transitional Care
Dawn I. Velligan, PhD | University of Texas Health Science Center at San Antonio | Study Location: Texas - Improving Delivery of Patient-Centered Cardiac Rehabilitation
Mary Whooley, MD | University of California San Francisco | Study Location: California, Massachusetts - Identifying Which Transitional Care Services Matter Most to Patients and Caregivers -- The ACHIEVE Study
Mark V. Williams, MD | University of Kentucky | Study Location: California, Colorado, Kentucky, Massachusetts, Pennsylvania - A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
Douglas F. Zatzick, MD | University of Washington | Study Location: Washington - Does Care Management Help Patients Recover from a Serious Injury?
Douglas F. Zatzick, MD | University of Washington | Study Location: Washington
You can also explore these projects by health condition, patient population, patient transition setting, or intervention strategy.
Past Events
2017 PCORI Annual Meeting
October 31-November 2, 2017, Washington, DC
- Breakout session titled "Why Methods Matter: Putting Research to Work for Individual Patients”
- Pre-Annual Meeting open session titled "2017 PCORI Transitional Care Evidence to Action Network Working Meeting"
- October 31, 2017; 1:00 pm - 3:00pm (ET)
- Presenters: Carly Parry (PCORI) Donna Carden, Jerry Krishnan, Pamela Duncan, Hanan Aboumatar, Matthew J. Reeves, Douglas Zatzick, and Russ Mardon
- Agenda (Draft)
2016 PCORI Annual Meeting
November 17-19, 2016, Washington, DC
- Breakout session titled “The Transitional Care Evidence to Action Network: Approach, Accomplishments, and Exemplars”
- Participants: Carly Parry (PCORI); Donna Carden and Dawn Rosini (Carden study); Douglas Zatzick and Peter Thomas (Zatzick study)
- Panel Presentation Slides
- Related feature story: Considering Patient Concerns during Trauma Care
Advancing the Science of Community-Engaged Research Conference
August 25-26, 2016, Washington, DC
- Learning Lab presentation titled “Partnering with Patients, Families, and other Stakeholders in Healthcare Systems Research: Examples and Lessons learned from Six PCORI-funded Studies”
- Participants: Hanan Aboumatar and Edna Shattuck (Aboumatar study); Julie Gassaway and Minna Hong (Jones study); Teri Browne (Boulware study); Hadley Sauers-Ford (Shah study); Lewis Hsu (Krishnan study); Barbara Lutz (Carden study); Sabina Gesell (Duncan study); Michelle Johnston-Fleece and Jaye Bea Smalley (PCORI)
Institute for Patient- and Family-Centered Care 2016 Annual Meeting
July 25-27, 2016, New York, NY
- Poster presentation titled “Engaging Patients and Families in Patient-Centered Outcomes Research on Care Transitions”
- Authors: Carol Levine (Williams study); Peter Thomas (Zatzick study); Carly Parry, Lauren Azar, and Michelle Johnston-Fleece (PCORI); Russ Mardon and Sari Siegel (Westat)
- PCORI Evidence to Action Network Poster (IPFCC), PDF
Health Care Systems Research Network (HCSRN) 2016 Annual Meeting
April 14-16, 2016, Atlanta, GA
- Panel presentation titled “A Comparison of Patient-Centered Transitional Care Interventions in Integrated versus Fee for Service Systems: Findings from the Transitional Care Evidence to Action Network”
- Participants: Dawn Velligan (PI); Jeffrey Schnipper (PI); Pamela Duncan (PI); Jerry Krishnan (PI); Steve Clauser and Carly Parry (PCORI)
8th Annual Conference on the Science of Dissemination & Implementation
December 14-15, 2015, Washington, DC
- Panel presentation titled “Developing sustainable strategies for the implementation of patient-centered care across diverse US healthcare systems”
- Participants: Doug Zatzick (PI), Jonathan Tobin, Michael Jones (PI)
- Related blog post: The Science of Dissemination & Implementation: An Important PCORI Focus
Providing Support and Addressing Barriers around Transitional Care
Transitional Care Research Network Helps Fill Gaps in Care
Providing Connections and Community around Transitional Care
What's Happening at PCORI?
The Patient-Centered Outcomes Research Institute sends weekly emails about opportunities to apply for funding, newly funded research studies and engagement projects, results of our funded research, webinars, and other new information posted on our site.
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