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 29 transitional care projects ($128 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 2020, these projects are at varying stages of research.
Explore Our Projects
Tubbs-Cooley HL, Riddle SW, Gold JM, Wade-Murphy S, Auger KA, Statile AM, Sucharew HS, Shah SS, Simmons JM, Pickler RH; H2O Study Group. Paediatric clinical and social concerns identified by home visit nurses in the immediate postdischarge period. J Adv Nurs. 2020 Mar 4. doi: 10.1111/jan.14341. [Epub ahead of print] (March 2020)
Scheuer H, Engstrom A, Thomas P, Moodliar R, Moloney K, Walen ML, Johnson P, Seo S, Vaziri N, Martinez A, Maier R, Russo J, Sieber S, Anziano P, Anderson K, Bulger E, Whiteside L, Heagerty P, Palinkas L, Zatzick D. A comparative effectiveness trial of an information technology enhanced peer-integrated collaborative care intervention versus enhanced usual care for US trauma care systems: Clinical study protocol. Contemp Clin Trials. 2020 Apr; 91:105970. doi: 10.1016/j.cct.2020.105970. (April 2020)
Aboumatar H, Naqibuddin M, Chung S, Chaudhry H, Kim SW, Saunders J, et al. Effect of a Hospital-Initiated Program Combining Transitional Care and Long-term Self-management Support on Outcomes of Patients Hospitalized With Chronic Obstructive Pulmonary Disease: A Randomized Clinical Trial. JAMA. 2019;322(14):1371-80. (October 2019)
Gesell SB, Bushnell CD, Jones SB, Coleman SW, Levy SM, Xenakis JG, Lutz BJ, Bettger JP, Freburger J, Halladay JR, Johnson AM, Kucharska-Newton AM, Mettam LH, Pastva AM, Psioda MA, Radman MD, Rosamond WD, Sissine ME, Halls J, Duncan PW. Implementation of a billable transitional care model for stroke patients: the COMPASS study. BMC Health Serv Res. 2019 Dec 19; 19(1):978. doi: 10.1186/s12913-019-4771-0. (December 2019)
Bettger JP, Jones SB, Kucharska-Newton AM, Freburger JK, Coleman SW, Mettam LH, Sissine ME, Gesell SB, Bushnell CD, Duncan PW, Rosamond WD. Meeting Medicare requirements for transitional care: Do stroke care and policy align? Neurology. 2019 Jan 11. (January 2019)
Halladay J, Bushnell C, Psioda M, Jones S, Lycan S, Condon C, Xenakis J, Prvu-Bettger J. Patient Factors Associated with Attendance at a Comprehensive Post-Acute Stroke Visit, Insight from the Vanguard Site. Archives of Rehabilitation Research and Clinical Translation. 2019 Dec. doi: 10.1016/j.arrct.2019.100037. (December 2019)
Grudzen CR, Schmucker AM, Shim DJ, Ibikunle A, Cho J, Chung FR, Cohen SE; EMPallA Outpatient Investigators. Development of an Outpatient Palliative Care Protocol to Monitor Fidelity in the Emergency Medicine Palliative Care Access Trial. J Palliat Med. 2019 Sep;22(S1):66-71. (September 2019)
Jones ML, Gassaway J, Sweatman WM. Peer mentoring reduces unplanned readmissions and improves self-efficacy following inpatient rehabilitation for individuals with spinal cord injury. J Spinal Cord Med. 2019 Aug 12:1-9. (August 2019)
Grudzen CR, Shim DJ, Schmucker AM, et al. Emergency Medicine Palliative Care Access (EMPallA): protocol for a multicenter randomised controlled trial comparing the effectiveness of specialty outpatient versus nurse-led telephonic palliative care of older adults with advanced illness. BMJ Open 2019;9:e025692. (January 2019)
Hughes AK, Woodward AT, Fritz MC, Swierenga SJ, Freddolino PP, Reeves MJ. Unmet Needs of US Acute Stroke Survivors Enrolled in a Transitional Care Intervention Trial. J Stroke Cerebrovasc Dis. 2019 Nov 22;104462. doi: 10.1016/j.jstrokecerebrovasdis.2019.104462. [Epub ahead of print]. PMID: 31761737. (November 2019)
Reeves MJ, Fritz MC, Woodward AT, Hughes AK, Coursaris CK, Swierenga SJ, Nasiri M, Freddolino PP. Michigan Stroke Transitions Trial. Circ Cardiovasc Qual Outcomes. 2019 Jul;12(7):e005493. (July 2019)
Statile AM, White CM, Sucharew HJ, Moore M, Tubbs-Cooley HL, Simmons JM, Shah SS, Auger KA; H2O Trial study group. Comparison of Parent Report with Administrative Data to Identify Pediatric Reutilization Following Hospital Discharge. J Hosp Med. 2019 Jul 1;14(7):411-414. (July 2019)
Thomas RJ, Beatty AL, Beckie TM, Brewer LC, Brown TM, Forman DE, Franklin BA, Keteyian SJ, Kitzman DW, Regensteiner JG, Sanderson BK, Whooley MA. Home-Based Cardiac Rehabilitation: A Scientific Statement From the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology. J Am Coll Cardiol. 2019 May 7. pii: S0735-1097(19)33874-4. (May 2019)
Tran H, Byatt N, Erskine N, Lessard D, Devereaux RS, Saczynski J, Kiefe C, Goldberg R. Impact of anxiety on the post-discharge outcomes of patients discharged from the hospital after an acute coronary syndrome. Int J Cardiol. 2018 Sep 20. pii: S0167-5273(18)34285-2. (September 2018)
Green JA, Ephraim PL, Hill-Briggs FF, Browne T, Strigo TS, Hauer CL, Stametz RA, Darer JD, Patel UD, Lang-Lindsey K, Bankes BL, Bolden SA, Danielson P, Ruff S, Schmidt L, Swoboda A, Woods P, Vinson B, Littlewood D, Jackson G, Pendergast JF, St Clair Russell J, Collins K, Norfolk E, Bucaloiu ID, Kethireddy S, Collins C, Davis D, dePrisco J, Malloy D, Diamantidis CJ, Fulmer S, Martin J, Schatell D, Tangri N, Sees A, Siegrist C, Breed J Jr, Medley A, Graboski E, Billet J, Hackenberg M, Singer D, Stewart S, Alkon A, Bhavsar NA, Lewis-Boyer L, Martz C, Yule C, Greer RC, Saunders M, Cameron B, Boulware LE. Putting patients at the center of kidney care transitions: PREPARE NOW, a cluster randomized controlled trial. Contemporary Clinical Trials (October 2018).
Auger KA, Shah SS, Tubbs-Cooley HL, Sucharew HJ, Gold JM, Wade-Murphy S, Statile AM, Bell KD, Khoury JC, Mangeot C, Simmons JM; Hospital-to-Home Outcomes Trial Study Group. Effects of a 1-Time Nurse-Led Telephone Call After Pediatric Discharge: The H2O II Randomized Clinical Trial. JAMA Pediatrics (September 2018).
Duncan PW, Abbott RM, Rushing S, Johnson AM, Condon CN, Lycan SL, Lutz BJ, Cummings DM, Pastva AM, D'Agostino RB Jr, Stafford JM, Amoroso RM, Jones SB, Psioda MA, Gesell SB, Rosamond WD, Prvu-Bettger J, Sissine ME, Boynton MD, Bushnell CD. COMPASS-CP: An Electronic Application to Capture Patient-Reported Outcomes to Develop Actionable Stroke and Transient Ischemic Attack Care Plans. Circulation: Cardiovascular Quality and Outcomes (August 2018).
Walker ER, Zahn R, Druss BG. Applying a Model of Stakeholder Engagement to a Pragmatic Trial for People With Mental Disorders. Psychiatric Services (August 2018).
Carty CL, Soghier LM, Kritikos KI, Tuchman LK, Jiggetts M, Glass P, Streisand R, Fratantoni KR. The giving parents support study: A randomized clinical trial of a parent navigator intervention to improve outcomes after neonatal intensive care unit discharge. Contemporary Clinical Trials (July 2018).
Beatty AL, Truong M, Schopfer DW, Shen H, Bachmann JM, Whooley MA. Geographic Variation in Cardiac Rehabilitation Participation in Medicare and Veterans Affairs Populations: Opportunity for Improvement. Circulation (May 2018).
Bushnell CD, Duncan PW, Lycan SL, Condon CN, Pastva AM, Lutz BJ, Halladay JR, Cummings DM, Arnan MK, Jones SB, Sissine ME, Coleman SW, Johnson AM, Gesell SB, Mettam LH, Freburger JK, Barton-Percival B, Taylor KM, Prvu-Bettger J, Lundy-Lamm G, Rosamond WD; COMPASS Trial. A Person-Centered Approach to Poststroke Care: The COMprehensive Post-Acute Stroke Services Model. Journal of the American Geriatrics Society (May 2018).
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).