Transitional Care Projects by Intervention Components
Community-Based Services
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery Among Patients with Chronic Obstructive Pulmonary Disease
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
- Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Rural Options At Discharge Model of Active Planning -- The ROADMAP Study
- Does Care Management Help Patients Recover from a Serious Injury?
- Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury
- Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
Discharge and Care Planning
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
- An Emergency Department-to-Home Intervention To Improve Quality Of Life And Reduce Hospital Use
- GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED -- The GUIDED HF Study
- Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
- Improving Care Transitions for Acute Stroke Patients through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Rural Options At Discharge Model of Active Planning -- The ROADMAP Study
- Improving Post-Discharge Outcomes by Facilitating Family-Centered Transitions from Hospital to Home
- Helping Patients with Mental Illness Engage in Their Transitional Care
- Improving Delivery of Patient-Centered Cardiac Rehabilitation
- A Comparative Effectiveness Trial of Optimal Patient-Centered Care for US Trauma Care Systems
- Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury
- Comparing Two Ways to Provide Palliative Care to Older Adults with Serious Illness
- A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
- Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
Education, Coaching, and Self-Management Support
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
- Can a Patient-Centered Approach to Preparing Patients for Kidney Failure Improve Patient Outcomes?
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
- GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED -- The GUIDED HF Study
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
- Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
- A Patient-Centered Approach to Successful Community Transition after Catastrophic Injury
- PATient Navigator to rEduce Readmissions -- The PArTNER Study
- Improving Care Transitions for Acute Stroke Patients through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Improving Post-Discharge Outcomes by Facilitating Family-Centered Transitions from Hospital to Home
- Helping Patients with Mental Illness Engage in Their Transitional Care
- Improving Delivery of Patient-Centered Cardiac Rehabilitation
- Does Care Management Help Patients Recover from a Serious Injury?
- Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury
- Comparing Two Ways to Provide Palliative Care to Older Adults with Serious Illness
- Comparative Effectiveness of Peer Mentoring versus Structured Education-Based Transition Programming for the Management of Care Transitions in Emerging Adults with Sickle Cell Disease
- Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
- Comparative Effectiveness of Direct Admission & Admission through Emergency Departments for Children
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
- Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
Home Visits
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
- GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED - The GUIDED HF Study
- PATient Navigator to rEduce Readmissions - The PArTNER Study
- Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Improving Post-Discharge Outcomes by Facilitating Family-Centered Transitions from Hospital to Home
- Improving Delivery of Patient-Centered Cardiac Rehabilitation
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
Medication Interventions
- Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
Non-Interventional Study
- Comparing Recovery Options for Stroke Patients
- Improving Measurement of Health Care Transitions through Key Stakeholders’ Eyes
- Identifying Which Transitional Care Services Matter Most to Patients and Caregivers - The ACHIEVE Study
Peer Support and/or Community Health Workers
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
- A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury
- PATient Navigator to rEduce Readmissions -- The PArTNER Study
- Does Care Management Help Patients Recover from a Serious Injury?
- A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
- Comparative Effectiveness of Peer Mentoring versus Structured Education-Based Transition Programming for the Management of Care Transitions in Emerging Adults with Sickle Cell Disease
- Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
- Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
Technology Interventions
- Can a Patient-Centered Approach to Preparing Patients for Kidney Failure Improve Patient Outcomes?
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury
- Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program
- Using a Transitional Care Program to Prepare Patients to Take Care of Themselves after Leaving the Hospital
- Does Care Management Help Patients Recover from a Serious Injury?
- A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
- Comparative Effectiveness of Peer Mentoring versus Structured Education-Based Transition Programming for the Management of Care Transitions in Emerging Adults with Sickle Cell Disease
- Community Health Workers and Mobile Health for Emerging Adults Transitioning Sickle Cell Disease Care -- The COMETS Study
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
- Improving Family-Centered Pediatric Trauma Care -- The Standard of Care versus the Virtual Pediatric Trauma Center
- Comparative Effectiveness Trial of Perioperative Telemonitoring for Functional Recovery and Symptoms
Telephone Follow Up
- An Integrative Multilevel Study for Improving Patient-Centered Care Delivery among Patients with Chronic Obstructive Pulmonary Disease
- Specialized Community Disease Management to Reduce Substance Use and Hospital Readmissions
- An Emergency Department-to-Home Intervention to Improve Quality of Life and Reduce Hospital Use
- GWTG Interventions to Reduce Disparities in AHF Patients Discharged from the ED -- The GUIDED HF Study
- Comparing Two Ways to Help Patients with Mental Illness Transition from the Emergency Department to Outpatient Care -- The EPIC Study
- Comparing Ways to Improve Daily Functioning for Stroke Survivors After They Leave the Hospital -- The COMPASS Study
- Can Peer Support after Newborns are in Intensive Care Improve Parents' Mental Health and Newborns' Outcomes?
- A Patient-Centered Approach to Successful Community Transition After Catastrophic Injury
- PATient Navigator to rEduce Readmissions -- The PArTNER Study
- Improving Care Transitions for Acute Stroke Patients Through a Patient-Centered Home-Based Case Management Program
- Improving Delivery of Patient-Centered Cardiac Rehabilitation
- Does Care Management Help Patients Recover from a Serious Injury?
- Improving Transition from Acute to Post-Acute Care Following Traumatic Brain Injury
- Comparing Two Ways to Provide Palliative Care to Older Adults with Serious Illness
- A Comparative Effectiveness Trial of an Information Technology Enhanced Peer-Integrated Collaborative Care Intervention for US Trauma Care Systems
- Using Mobile Integrated Health and Telehealth to Support Transitions of Care among Heart Failure Patients
- Examination of the Evidence-Based Care Transitions Intervention Enhanced with Peer Support to Reduce Racial Disparities in Hospital Readmissions and Negative Outcomes Post-Hospitalization
- Comparative Effectiveness Trial of Perioperative Telemonitoring for Functional Recovery and Symptoms
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