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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
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1 to 1 of 1 Research Studies DisplayedHewner 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