National Healthcare Quality and Disparities Report
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Topics
- Access to Care (1)
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- (-) Care Coordination (106)
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- Provider: Clinician (1)
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- Quality Indicators (QIs) (3)
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- Screening (1)
- Social Determinants of Health (2)
- Stroke (2)
- Surgery (6)
- Teams (10)
- Telehealth (2)
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- Transitions of Care (23)
- Trauma (3)
- Urban Health (1)
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
51 to 75 of 106 Research Studies DisplayedSenft N, Everson J
eHealth engagement as a response to negative healthcare experiences: cross-sectional survey analysis.
The goal of this study was to determine how the negative healthcare experiences of low patient centeredness and care coordination problems motivate the use of different eHealth activities, and whether more highly educated individuals are more likely than those less highly educated to use eHealth following negative experiences. Researchers used factor analysis to group 25 different eHealth activities into categories, based on the correlation between respondents' reports of their usage. Their findings indicate that individuals use a greater number of eHealth activities, especially activities independent of healthcare providers, when they experience problems with their healthcare; people with lower levels of education who have had negative healthcare experiences seem more inclined to use eHealth. The researchers recommend that, in order to maximize the potential for eHealth to meet the needs of all patients, especially those who are underserved, additional work is needed to ensure that eHealth resources are accessible to all members of the population.
AHRQ-funded; HS026122.
Citation: Senft N, Everson J .
eHealth engagement as a response to negative healthcare experiences: cross-sectional survey analysis.
J Med Internet Res 2018 Dec 5;20(12):e11034. doi: 10.2196/11034..
Keywords: Care Coordination, Electronic Health Records (EHRs), Health Information Technology (HIT), Patient-Centered Healthcare, Patient Experience, Telehealth
I Auerbach, M Badaki-Makun, O
AHRQ Author: Barata
A research agenda to advance pediatric emergency care through enhanced collaboration across emergency departments.
In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital."
AHRQ-funded; HS026101.
Citation: I Auerbach, M Badaki-Makun, O .
A research agenda to advance pediatric emergency care through enhanced collaboration across emergency departments.
Acad Emerg Med 2018 Dec;25(12):1415-26. doi: 10.1111/acem.13642..
Keywords: Care Coordination, Children/Adolescents, Emergency Department, Evidence-Based Practice, Health Services Research (HSR), Outcomes, Quality of Care, Quality Improvement
Kranz AM, Dalton S, Damberg C
Using health IT to coordinate care and improve quality in safety-net clinics.
Health centers provide care to vulnerable and high-need populations. Recent investments have promoted use of health information technology (HIT) capabilities for improving care coordination and quality of care in health centers. This study examined factors associated with use of these HIT capabilities and the association between these capabilities and quality of care in a census of health centers in the United States.
AHRQ-funded; HS024067.
Citation: Kranz AM, Dalton S, Damberg C .
Using health IT to coordinate care and improve quality in safety-net clinics.
Jt Comm J Qual Patient Saf 2018 Dec;44(12):731-40. doi: 10.1016/j.jcjq.2018.03.006..
Keywords: Health Information Technology (HIT), Care Coordination, Patient-Centered Healthcare, Quality Improvement, Quality of Care, Vulnerable Populations, Care Management
Moise N, Shah RN, Essock S
Sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State.
This study examined sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State. The investigators used descriptive statistics to assess implementation metrics in sustaining vs. opt-out clinics and trends in implementation fidelity 1 and 2 years into the sustainability phase among sustaining clinics.
AHRQ-funded; HS025198
Citation: Moise N, Shah RN, Essock S .
Sustainability of collaborative care management for depression in primary care settings with academic affiliations across New York State.
Implement Sci 2018 Oct 12;13(1):128. doi: 10.1186/s13012-018-0818-6..
Keywords: Care Coordination, Depression, Behavioral Health, Primary Care
Auger KA, Shah SS, Tubbs-Cooley HL
Effects of a 1-time nurse-led telephone call after pediatric discharge: the H2O II randomized clinical trial.
The purpose of this study was to determine whether a single nurse-led telephone call after pediatric discharge decreased the 30-day reutilization rate for urgent care services and enhanced overall transition success. The investigators concluded that although postdischarge nurse contact did not decrease the reutilization rate of postdischarge urgent health care services, the method showed promise to bolster postdischarge education.
AHRQ-funded; HS024735.
Citation: Auger KA, Shah SS, Tubbs-Cooley HL .
Effects of a 1-time nurse-led telephone call after pediatric discharge: the H2O II randomized clinical trial.
JAMA Pediatr 2018 Sep;172(9):e181482. doi: 10.1001/jamapediatrics.2018.1482..
Keywords: Care Coordination, Children/Adolescents, Health Information Technology (HIT), Health Services Research (HSR), Healthcare Delivery, Healthcare Utilization, Hospital Discharge, Outcomes, Provider, Provider: Nurse, Telehealth, Transitions of Care
Walker DM
Does participation in health information exchange improve hospital efficiency?.
This study strives to answer the question: does health information exchange (HIE) network participation improve hospital efficiency? The results of the study suggest that hospital investment in HIE participation may be a useful strategy to improve hospital operational performance, and that policy should continue to support increased participation and use of HIE.
AHRQ-funded; HS023343.
Citation: Walker DM .
Does participation in health information exchange improve hospital efficiency?.
Health Care Manag Sci 2018 Sep;21(3):426-38. doi: 10.1007/s10729-017-9396-4..
Keywords: Care Coordination, Quality of Care, Health Information Technology (HIT), Hospitals, Health Information Exchange (HIE)
Desai AD, Jacob-Files EA, Wignall J
Caregiver and health care provider perspectives on cloud-based shared care plans for children with medical complexity.
Shared care plans play an essential role in coordinating care across health care providers and settings for children with medical complexity (CMC). However, existing care plans often lack shared ownership, are out-of-date, and lack universal accessibility. In this study, the investigators aimed to establish requirements for shared care plans to meet the information needs of caregivers and providers and to mitigate current information barriers when caring for CMC.
AHRQ-funded; HS024299.
Citation: Desai AD, Jacob-Files EA, Wignall J .
Caregiver and health care provider perspectives on cloud-based shared care plans for children with medical complexity.
Hosp Pediatr 2018 Jul;8(7):394-403. doi: 10.1542/hpeds.2017-0242..
Keywords: Children/Adolescents, Caregiving, Chronic Conditions, Care Coordination, Healthcare Delivery
Arthur KC, Mangione-Smith R, Burkhart Q
Quality of care for children with medical complexity: an analysis of continuity of care as a potential quality indicator.
The objective of this study was to examine the relationship between continuity of care for children with medical complexity (CMC) and emergency department (ED) utilization, care coordination quality, and family effects related to care coordination. The investigators measured ED utilization and primary care continuity with the Bice-Boxerman continuity of care index for 1477 CMC using administrative data from Minnesota and Washington state Medicaid agencies. They concluded that continuity of care holds promise as a quality measure for CMC because of its association with lower ED utilization and more frequent receipt of care coordination.
AHRQ-funded; HS020506.
Citation: Arthur KC, Mangione-Smith R, Burkhart Q .
Quality of care for children with medical complexity: an analysis of continuity of care as a potential quality indicator.
Acad Pediatr 2018 Aug;18(6):669-76. doi: 10.1016/j.acap.2018.04.009..
Keywords: Care Coordination, Children/Adolescents, Chronic Conditions, Emergency Department, Healthcare Utilization, Primary Care, Quality of Care, Quality Indicators (QIs), Quality Measures
Parast L, Burkhart Q, Gidengil C
Validation of new care coordination quality measures for children with medical complexity.
The purpose of this paper was to validate new caregiver-reported quality measures assessing care coordination services for children with medical complexity (CMC). Results showed that 19 newly-developed Family Experiences with Coordination of Care quality measures demonstrated convergent validity with previously-validated CAHPS measures. These new measures are valid for assessing the quality of care coordination services provided to CMC and may be useful for evaluating new models of care focused on improving these services.
AHRQ-funded; HS020506.
Citation: Parast L, Burkhart Q, Gidengil C .
Validation of new care coordination quality measures for children with medical complexity.
Acad Pediatr 2018 Jul;18(5):581-88. doi: 10.1016/j.acap.2018.03.006..
Keywords: Care Coordination, Children/Adolescents, Chronic Conditions, Consumer Assessment of Healthcare Providers and Systems (CAHPS), Patient Experience, Quality Indicators (QIs), Quality Measures, Quality Improvement, Quality of Care
Yao Y, Ahn H, Stifter J
Continuity index measures in the acute care hospital setting: an analytic review and tests using electronic health record data and computer simulation.
This study examined continuity index measures in the acute care hospital setting. These measures can be used to examine the influence of nurse staffing patterns on patient outcomes. The researchers examined the behavior of continuity indexes as applied to clinical practice data that were collected with the Hands-On Automated Nursing Data System (HANDS) and data from computer simulation. The findings provided a deep understanding of the conceptual foundations and properties of various continuity measures.
AHRQ-funded; HS015054; HS023072.
Citation: Yao Y, Ahn H, Stifter J .
Continuity index measures in the acute care hospital setting: an analytic review and tests using electronic health record data and computer simulation.
J Nurs Meas 2018 Apr 1;26(1):20-35. doi: 10.1891/1061-3749.26.1.20..
Keywords: Transitions of Care, Care Coordination, Electronic Health Records (EHRs), Health Information Technology (HIT), Provider: Nurse, Provider, Hospitals, Outcomes
Everson J, Funk RJ, Kaufman SR
Repeated, close physician coronary artery bypass grafting teams associated with greater teamwork.
This study sought to determine whether observed patterns of physician interaction around shared patients are associated with higher levels of teamwork as perceived by physicians. It found that in hospitals where physicians repeatedly cared for patients with the same colleagues, physicians perceived better teamwork. When physicians who worked together also had other colleagues in common, the reported teamwork was stronger.
AHRQ-funded; HS024525; HS024728.
Citation: Everson J, Funk RJ, Kaufman SR .
Repeated, close physician coronary artery bypass grafting teams associated with greater teamwork.
Health Serv Res 2018 Apr;53(2):1025-41. doi: 10.1111/1475-6773.12703.
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Keywords: Cardiovascular Conditions, Care Coordination, Communication, Surgery, Teams
Feder SL, Britton MC, Chaudhry SI
"They need to have an understanding of why they're coming here and what the outcomes might be." Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities.
This study examined how clinicians view goals of care (GoC) for hospitalized patients discharged to skilled nursing facilities (SNFs). A variety of clinicians were interviewed: 22% were nurses, 20% physicians, 15% from care management, and 15% from social services. Many respondents felt that patients and their families had unrealistic GoCs. However, conversations on GoCs were infrequent during hospitalizations which contribute to unrealistic expectations for SNF care and poor patient outcomes. The researchers recommend interventions to ensure that GoC conversations and are held regularly and in a timely manner before transfer occurs.
AHRQ-funded; HS023554.
Citation: Feder SL, Britton MC, Chaudhry SI .
"They need to have an understanding of why they're coming here and what the outcomes might be." Clinician perspectives on goals of care for patients discharged from hospitals to skilled nursing facilities.
J Pain Symptom Manage 2018 Mar;55(3):930-37. doi: 10.1016/j.jpainsymman.2017.10.013..
Keywords: Care Coordination, Clinician-Patient Communication, Communication, Hospital Discharge, Nursing Homes, Patient and Family Engagement, Provider: Clinician, Provider: Nurse, Provider: Physician
Turner AM, Osterhage K, Loughran J
Emergency information management needs and practices of older adults: a descriptive study.
The purpose of this study was to better understand how older adults manage emergency information, the barriers and facilitators to planning and management of emergency information, as well as the potential role of information technology to facilitate emergency planning and management. The investigators found that emergency information, such as emergency contact information, diagnoses, and advance directives, is a type of health information that older adults manage.
AHRQ-funded; HS022106.
Citation: Turner AM, Osterhage K, Loughran J .
Emergency information management needs and practices of older adults: a descriptive study.
Int J Med Inform 2018 Mar;111:149-58. doi: 10.1016/j.ijmedinf.2017.12.001..
Keywords: Care Coordination, Elderly, Health Information Technology (HIT), Healthcare Delivery, Health Information Technology (HIT)
Tomoaia-Cotisel A, Farrell TW, Solberg LI
AHRQ Author: Harrison MI, Genevro JL
Implementation of care management: an analysis of recent AHRQ research.
This article describes care management (CM) implementation and associated lessons from 12 Agency for Healthcare Research and Quality-sponsored projects. Two rounds of data collection resulted in project-specific narratives that were analyzed using an iterative approach analogous to framework analysis. Informants also participated as coauthors. Variation emerged across practices and over time regarding CM services provided, personnel delivering these services, target populations, and setting(s).
AHRQ-authored; AHRQ-funded; HS021933; 2902007.
Citation: Tomoaia-Cotisel A, Farrell TW, Solberg LI .
Implementation of care management: an analysis of recent AHRQ research.
Med Care Res Rev 2018 Feb;75(1):46-65. doi: 10.1177/1077558716673459.
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Keywords: Care Coordination, Patient-Centered Healthcare, Primary Care, Implementation
Kaiser SV, Rodean J, Bekmezian A
Rising utilization of inpatient pediatric asthma pathways.
The objectives of this study were to: 1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network and (2) Compare characteristics of hospitals with and without pathways. The investigators concluded that from 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. They found variation in many aspects of pathway design and implementation.
AHRQ-funded; HS024554; HS024592.
Citation: Kaiser SV, Rodean J, Bekmezian A .
Rising utilization of inpatient pediatric asthma pathways.
J Asthma 2018 Feb;55(2):196-207. doi: 10.1080/02770903.2017.1316392..
Keywords: Asthma, Care Coordination, Children/Adolescents, Inpatient Care
Raffo JE, Lloyd C, Collier M
Defining the role of the community health worker within a federal healthy start care coordination team.
The Strong Beginnings program worked to define community health worker (CHW) interventions, a core service of the program to improve maternal and child health. The workgroup identified seven core functions and 28 maternal and child health risk topics to be addressed by the CHW. The process resulted in a detailed document of program interventions that the CHWs use to guide care.
AHRQ-funded; HS020208.
Citation: Raffo JE, Lloyd C, Collier M .
Defining the role of the community health worker within a federal healthy start care coordination team.
Matern Child Health J 2017 Dec;21(Suppl 1):93-100. doi: 10.1007/s10995-017-2379-8.
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Keywords: Care Coordination, Children/Adolescents, Health Promotion, Health Services Research (HSR), Maternal Care
Jones CD, Jones J, RIchard A
"Connecting the Dots": a qualitative study of home health nurse perspectives on coordinating care for recently discharged patients.
This study described home health care (HHC) nurse perspectives about challenges and solutions to coordinating care for recently discharged patients. HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis.
AHRQ-funded; HS024569.
Citation: Jones CD, Jones J, RIchard A .
"Connecting the Dots": a qualitative study of home health nurse perspectives on coordinating care for recently discharged patients.
J Gen Intern Med 2017 Oct;32(10):1114-21. doi: 10.1007/s11606-017-4104-0.
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Keywords: Care Coordination, Elderly, Home Healthcare, Health Services Research (HSR), Hospital Discharge
Walker J, Crotty BH, O'Brien J
Addressing the challenges of aging: how elders and their care partners seek information.
Elders in retirement communities face many challenges concerning information and communication. The purpose of this study was to gain insights into how these elders and their families manage health information and communication. The study suggests that elders in senior living communities, and their families, piece together information primarily from word of mouth communication. It asserts that electronic social and collaborative technologies may make information gathering easier.
AHRQ-funded; HS021495.
Citation: Walker J, Crotty BH, O'Brien J .
Addressing the challenges of aging: how elders and their care partners seek information.
Gerontologist 2017 Oct 1;57(5):955-62. doi: 10.1093/geront/gnw060..
Keywords: Elderly, Caregiving, Communication, Care Coordination, Patient and Family Engagement, Health Information Technology (HIT)
McHugh JP, Foster A, Mor V JP, Foster A, Mor V
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
This study used a concurrent mixed-methods approach to examine changes in rehospitalization rates and differences in practices between hospitals that did and did not develop formal skilled nursing facilities (SNF) networks.
AHRQ-funded; HS023961.
Citation: McHugh JP, Foster A, Mor V JP, Foster A, Mor V .
Reducing hospital readmissions through preferred networks of skilled nursing facilities.
Health Aff 2017 Sep;36(9):1591-98. doi: 10.1377/hlthaff.2017.0211..
Keywords: Care Coordination, Hospital Readmissions, Hospitals, Nursing Homes, Transitions of Care
Hewner S, Casucci S, Sullivan S
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
Care continuity during transitions between the hospital and home requires reliable communication between providers and settings and an understanding of social determinants that influence recovery. This paper describes the coordinating transitions intervention which uses real time alerts, delivered directly to the primary care practice for complex chronically ill patients discharged from an acute care setting, to facilitate nurse care coordinator led telephone outreach.
AHRQ-funded; HS022575.
Citation: Hewner S, Casucci S, Sullivan S .
Integrating social determinants of health into primary care clinical and informational workflow during care transitions.
eGEMS 2017 Jul 4;5(2):2. doi: 10.13063/2327-9214.1282..
Keywords: Care Coordination, Chronic Conditions, Patient-Centered Healthcare, Social Determinants of Health, Transitions of Care
Jones CD, Bowles KH, Richard A
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Providing home health nursing and therapy could promote recovery in vulnerable HF patients with post-hospital syndrome and potentially reduce readmissions. The authors argue that understanding the characteristics of effective post-acute HHC for patients with HF will inform best practices, optimal outcomes for cost, and ultimately high-value care.
AHRQ-funded; HS024569.
Citation: Jones CD, Bowles KH, Richard A .
High-value home health care for patients with heart failure: an opportunity to optimize transitions from hospital to home.
Circ Cardiovasc Qual Outcomes 2017 May;10(5). doi: 10.1161/circoutcomes.117.003676.
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Keywords: Home Healthcare, Heart Disease and Health, Transitions of Care, Care Coordination, Medicare
Duckworth M, Leung E, Fuller T
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Differences emerged stemming from each group of end users' role on the care team.
AHRQ-funded; HS023535.
Citation: Duckworth M, Leung E, Fuller T .
Nurse, patient, and care partner perceptions of a personalized safety plan screensaver.
J Gerontol Nurs 2017 Apr;43(4):15-22. doi: 10.3928/00989134-20170313-05.
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Keywords: Elderly, Electronic Health Records (EHRs), Health Information Technology (HIT), Caregiving, Patient Safety, Patient and Family Engagement, Care Coordination
Quintana Y, Crotty B, Fahy D
InfoSAGE: use of online technologies for communication and elder care.
To identify how information and communication needs evolved with the aging process, the study authors created a living laboratory of families, supported by an online private social network with tools for care coordination.
AHRQ-funded; HS021495.
Citation: Quintana Y, Crotty B, Fahy D .
InfoSAGE: use of online technologies for communication and elder care.
Stud Health Technol Inform 2017;234:280-85..
Keywords: Care Coordination, Healthcare Delivery, Communication, Elderly, Health Information Technology (HIT)
Abraham J, Kannampallil TG, Patel VL
Impact of structured rounding tools on time allocation during multidisciplinary rounds: an observational study.
The aim of this study was to investigate whether disproportionate time allocation effects during multidisciplinary rounds (MDRs) persist with the use of structured rounding tools. It concluded that the use of structured rounding tools potentially mitigates disproportionate time allocation and communication breakdowns during rounds with the more structured system-based Handoff Intervention Tool (HAND-IT), almost completely eliminating such effects.
AHRQ-funded; HS017586.
Citation: Abraham J, Kannampallil TG, Patel VL .
Impact of structured rounding tools on time allocation during multidisciplinary rounds: an observational study.
JMIR Hum Factors 2016 Dec 09;3(2):e29. doi: 10.2196/humanfactors.6642.
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Keywords: Tools & Toolkits, Clinician-Patient Communication, Teams, Health Information Technology (HIT), Care Coordination
Sherry M, Wolff JL, Ballreich J
Bridging the silos of service delivery for high-need, high-cost individuals.
This study examined 5 innovative community-oriented programs that are successfully coordinating medical and nonmedical services to identify factors that stimulate and sustain community-level collaboration and coordinated care across silos of health care, public health, and social services delivery. The authors constructed a conceptual framework depicting community health systems that highlights 4 foundational factors that facilitate community-oriented collaboration.
AHRQ-funded; HS000029.
Citation: Sherry M, Wolff JL, Ballreich J .
Bridging the silos of service delivery for high-need, high-cost individuals.
Popul Health Manag 2016 Dec;19(6):421-28. doi: 10.1089/pop.2015.0147.
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Keywords: Community-Based Practice, Healthcare Costs, Healthcare Delivery, Care Coordination