PCORI funds research comparing which approaches work best to optimize care delivery as patients move between clinicians and care settings.
Research We Support
PCORI’s research in transitional care generates evidence that will help patients and their families, clinicians, payers, and policy makers make better-informed decisions about which transitional care services are most effective, given patients’ needs and circumstances.
To date, PCORI has funded 26 transitional care projects (over $120 million) across 16 states and the District of Columbia. These target a range of diseases and conditions (e.g., stroke, heart disease), patient populations (e.g., Medicare beneficiaries, rural-dwelling patients, children), and settings (e.g., hospital, emergency department, home). Funded between 2013 and 2019, these projects are at varying stages of research.
Explore Our Projects
Hughes AK, Woodward AT, Fritz MC, Reeves MJ. Improving stroke transitions: Development and implementation of a social work case management intervention. Social Work in Health Care (February 2018).
Johnson AM, Jones SB, Duncan PW, Bushnell CD, Coleman SW, Mettam LH, Kucharska-Newton AM, Sissine ME, Rosamond WD. Hospital recruitment for a pragmatic cluster-randomized clinical trial: Lessons learned from the COMPASS study. Trials (January 2018).
Mitchell SE, Laurens V, Weigel GM, Hirschman KB, Scott AM, Nguyen HQ, Howard JM, Laird L, Levine C, Davis TC, Gass B, Shaid E, Li J, Williams MV, Jack BW. Care Transitions From Patient and Caregiver Perspectives. Annals of Family Medicine (May/June 2018).
Zatzick D, Russo J, Thomas P, Darnell D, Teter H, Ingraham L, Whiteside LK, Wang J, Guiney R, Parker L, Sandgren K, Hedrick MK, Van Eaton EG, Jurkovich G. Patient-Centered Care Transitions After Injury Hospitalization: A Comparative Effectiveness Trial. Psychiatry: Interpersonal and Biological Processes (March 2018).
Aboumatar H, Naqibuddin M, Chung S, Adebowale H, Bone L, Brown T, Cooper LA, Gurses AP, Knowlton A, Kurtz D, Piet L, Putcha N, Rand C, Roter D, Shattuck E, Sylvester C, Urteaga-Fuentes A, Wise R, Wolff JL, Yang T, Hibbard J, Howell E, Myers M, Shea K, Sullivan J, Syron L, Wang NY, Pronovost P; BREATHE Study Patient Family Partners Group. Better Respiratory Education and Treatment Help Empower (BREATHE) study: Methodology and baseline characteristics of a randomized controlled trial testing a transitional care program to improve patient-centered care delivery among chronic obstructive pulmonary disease patients. Contemporary Clinical Trials (November 2017).
Bettger JP, Thomas L, Liang L, Xian Y, Bushnell CD, Saver JL, Fonarow GC, Peterson ED. Hospital Variation in Functional Recovery After Stroke. Circulation. Cardiovascular Quality and Outcomes (January 2017).
Collins SP, Levy PD, Holl JL, Butler J, Khan Y, Israel TL, Fonarow GC, Alikhaani J, Sarno E, Cook A, Yancy CW. Incorporating Patient and Caregiver Experiences Into Cardiovascular Clinical Trial Design. JAMA Cardiology (November 2017).
Duncan PW, Bushnell CD, Rosamond WD, Jones Berkeley SB, Gesell SB, D'Agostino RB Jr, Ambrosius WT, Barton-Percival B, Bettger JP, Coleman SW, Cummings DM, Freburger JK, Halladay J, Johnson AM, Kucharska-Newton AM, Lundy-Lamm G, Lutz BJ, Mettam LH, Pastva AM, Sissine ME, Vetter B. The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial BMC Neurology (July 2017).
Fermann GJ, Levy PD, Pang P, Butler J, Ayaz SI, Char D, Dunn P, Jenkins CA, Kampe C, Khan Y, Kumar VA, Lindenfeld J, Liu D, Miller K, Peacock WF, Rizk S, Robichaux C, Rothman RL, Schrock J, Singer A, Sterling SA, Storrow AB, Walsh C, Wilburn J, Collins SP. Design and Rationale of a Randomized Trial of a Care Transition Strategy in Patients With Acute Heart Failure Discharged From the Emergency Department: GUIDED-HF (Get With the Guidelines in Emergency Department Patients With Heart Failure) Circulation Heart Failure (February 2017).
Gassaway J, Jones ML, Sweatman WM, Hong M, Anziano P, DeVault K. Effects of Peer Mentoring on Self-Efficacy and Hospital Readmission After Inpatient Rehabilitation of Individuals With Spinal Cord Injury: A Randomized Controlled Trial. Archives of Physical Medicine and Rehabilitation (August 2017).
Gesell SB, Klein KP, Halladay J, Bettger JP, Freburger J, Cummings DM, Lutz BJ, Coleman S, Bushnell C, Rosamond W, Duncan PW. Methods guiding stakeholder engagement in planning a pragmatic study on changing stroke systems of care. Journal of Clinical and Translational Science (April 2017).
Lutz BJ, Hall AG, Vanhille SB, Jones AL, Schumacher JR, Hendry P, Harman JS, Carden DL. A Framework Illustrating Care-Seeking Among Older Adults in a Hospital Emergency Department. The Gerontologist (June 2017).
Naylor MD, Shaid EC, Carpenter D, Gass B, Levine C, Li J, Malley A, McCauley K, Nguyen HQ, Watson H, Brock J, Mittman B, Jack B, Mitchell S, Callicoatte B, Schall J, Williams MV. Components of Comprehensive and Effective Transitional Care. Journal of American Geriatrics Society (June 2017).
Reeves MJ, Hughes AK, Woodward AT, Freddolino PP, Coursaris CK, Swierenga SJ, Schwamm LH, Fritz MC. Improving transitions in acute stroke patients discharged to home: the Michigan stroke transitions trial (MISTT) protocol. BMC Neurology (June 2017).
Roberts DL, Velligan DI, Fredrick M. The Use of Access Groups for Engagement in Community Mental Health Post Hospitalization. Community Mental Health Journal (November 2017).
Rohrbach G, Schopfer DW, Krishnamurthi N, Pabst M, Bettencourt M, Loomis J, Whooley MA. The design and implementation of a home-based cardiac rehabilitation program. Federal Practitioner (May 2017).
Sauers-Ford HS, Gold JM, Statile AM, Tubbs-Cooley HL, Simmons JM, Shah SS, Bell K, Pfefferman C, Moore MJ, Auger KA; H2O Study Group. Improving Recruitment and Retention Rates in a Randomized Controlled Trial. Pediatrics. (May 2017).
Sauers-Ford H, Tubbs-Cooley H, Statile A, Pickler R, White C, Wade-Murphy S, Gold J, Shah S, Simmons J, H2O Study Group. Optimizing a Nurse-led Transitional Home Visit Program in Preparation for a Randomized Control Trial. Pediatric Quality and Safety (January 2017).
Schumacher JR, Lutz BJ, Hall AG, Pines JM, Jones AL, Hendry P, Kalynych C, Carden DL. Feasibility of an ED-to-Home Intervention to Engage Patients: A Mixed-Methods Investigation. The Western Journal of Emergency Medicine (June 2017).
Scott AM, Li J, Oyewole-Eletu S, Nguyen HQ, Gass B, Hirschman KB, Mitchell S, Hudson SM, Williams MV; Project ACHIEVE Team. Understanding Facilitators and Barriers to Care Transitions: Insights from Project ACHIEVE Site Visits. Joint Commission Journal on Quality and Patient Safety (September 2017).
Velligan DI, Fredrick MM, Sierra C, Hillner K, Kliewer J, Roberts DL, Mintz J. Engagement-focused care during transitions from inpatient and emergency psychiatric facilities. Patient Preference and Adherence (May 2017).
Xian Y, Thomas L, Liang L, Federspiel JJ, Webb LE, Bushnell CD, Duncan PW, Schwamm LH, Stein J, Fonarow GC, Hoenig H, Montalvo C, George MG, Lutz BJ, Peterson ED, Bettger JP. Unexplained Variation for Hospitals' Use of Inpatient Rehabilitation and Skilled Nursing Facilities After an Acute Ischemic Stroke. Stroke. (October 2017).
Beck AF, Solan LG, Brunswick SA, Sauers-Ford H, Simmons JM, Shah S, Gold J, Sherman SN; H2O Study Group. Socioeconomic Status Influences the Toll Paediatric Hospitalisations Take on Families: A Qualitative Study. BMJ Quality & Safety (July 2016).
Condon C, Lycan S, Duncan P, Bushnell C. Reducing Readmissions After Stroke With a Structured Nurse Practitioner/Registered Nurse Transitional Stroke Program Stroke (June 2016).
Fonarow GC, Liang L, Thomas L, Xian Y, Saver JL, Smith EE, Schwamm LH, Peterson ED, Hernandez AF, Duncan PW, O'Brien EC, Bushnell C, Prvu Bettger J. Assessment of Home-Time After Acute Ischemic Stroke in Medicare Beneficiaries. Stroke. (March 2016).
Li J, Brock J, Jack B, Mittman B, Naylor M, Sorra J, Mays G, Williams MV; Project ACHIEVE Team. Project ACHIEVE - Using Implementation Research to Guide the Evaluation of Transitional Care Effectiveness. BMC Health Services Research (February 2016).
Tubbs-Cooley HL, Pickler RH, Simmons JM, Auger KA, Beck AF, Sauers-Ford HS, Sucharew H, Solan LG, White CM, Sherman SN, Statile AM, Shah SS; H2O Study Group. Testing a Post-Discharge Nurse-led Transitional Home Visit in Acute Care Pediatrics: The Hospital-to-Home Outcomes (H2O) Study Protocol. Journal of Advanced Nursing (January 2016).
Ursan ID, Krishnan JA, Pickard AS, Calhoun E, DiDomenico R, Prieto-Centurion V, et al. Engaging Patients and Caregivers to Design Transitional Care Management Services at a Minority Serving Institution. Journal of Health Care for the Poor & Underserved (February 2016).
Velligan DI, Roberts DL, Sierra C, Fredrick MM, Roach MJ. What Patients With Severe Mental Illness Transitioning From Hospital to Community Have to Say About Care and Shared Decision-Making. Issues In Mental Health Nursing (June 2016).
H.S. Sauers-Ford, J.M. Simmons, S.S. Shah; H2O Study Team. Strategies to Engage Stakeholders in Research to Improve Acute Care Delivery. Journal of Hospital Medicine (September 2015).
Solan LG, Beck AF, Brunswick SA, Sauers HS, Wade-Murphy S, Simmons JM, Shah SS, Sherman SN; H2O Study Group. The Family Perspective on Hospital to Home Transitions: A Qualitative Study. Pediatrics (December 2015).
Velligan DI, Roberts D, Martinez M, Fredrick M, Hillner K, Luber P. Following AACP Guidelines for Transitions in Care: The Transitional Care Clinic. Psychiatric Services (March 2016).
Prieto-Centurion V, Markos MA, Ramey NI, Gussin HA, Nyenhuis SM, Joo MJ, Prasad B, Bracken N, Didomenico R, Godwin PO, Jaffe HA, Kalhan R, Pickard AS, Pittendrigh BR, Schatz B, Sullivan JL, Thomashow BM, Williams MV, Krishnan JA. Interventions to Reduce Rehospitalizations after Chronic Obstructive Pulmonary Disease Exacerbations. A Systematic Review. Annals of the American Thoracic Society (March 2014).