National Healthcare Quality and Disparities Report
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Topics
- Asthma (1)
- Autism (1)
- Behavioral Health (1)
- Cancer (1)
- Cardiovascular Conditions (1)
- (-) Care Coordination (19)
- Caregiving (3)
- Care Management (2)
- Children/Adolescents (5)
- Chronic Conditions (6)
- Communication (2)
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- Heart Disease and Health (1)
- Home Healthcare (2)
- Hospital Discharge (3)
- Hospital Readmissions (1)
- Hospitals (2)
- Implementation (1)
- Low-Income (1)
- Maternal Care (1)
- Medicare (1)
- Nursing Homes (1)
- Patient-Centered Healthcare (3)
- Patient and Family Engagement (3)
- Patient Safety (2)
- Patient Self-Management (1)
- Primary Care (1)
- Primary Care: Models of Care (1)
- Quality Improvement (1)
- Quality of Care (2)
- Racial and Ethnic Minorities (1)
- Social Determinants of Health (1)
- Stroke (1)
- Teams (2)
- Transitions of Care (7)
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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
1 to 19 of 19 Research Studies DisplayedVasan A, Kyle MA, Venkataramani AS
Inequities in time spent coordinating care for children and youth with special health care needs.
The purpose of this cross-sectional study was to examine sociodemographic inequities in time spent coordinating care for children and youth with special health care needs (CYSHCN) and examine the relationship between time spent coordinating care and forgone medical care. The study utilized 2018-2020 data from the National Survey of Children's Health, which included 102,740 children across all 50 states. The researchers characterized the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). Race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN were examined, and multivariable logistic regression was utilized to explore the relationship between time spent coordinating care and forgone medical care. The study found that over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent 5 hours per week or more on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was related with an increasing probability of forgone medical care.
AHRQ-funded; HS028555.
Citation: Vasan A, Kyle MA, Venkataramani AS .
Inequities in time spent coordinating care for children and youth with special health care needs.
Acad Pediatr 2023 Nov-Dec; 23(8):1526-34. doi: 10.1016/j.acap.2023.03.002..
Keywords: Children/Adolescents, Care Coordination, Vulnerable Populations, Disparities
Kornfield R, Lattie EG, Nicholas J
"Our job is to be so temporary": designing digital tools that meet the needs of care managers and their patients with mental health concerns.
The purpose of this study was to improve understanding of how to integrate digital tools in routine healthcare, especially for patients with both physical and mental health needs. The researchers conducted interviews and design workshops with 1. a group of care managers who support patients with complex health needs, and 2. their patients whose health needs include mental health concerns. The researchers examined both groups' views of potential applications of digital tools within care management. The study found that care managers felt underprepared to addressing mental health issues on an ongoing basis and had concerns about the burden and confusion of providing support through new digital channels. Patients envisioned benefiting from ongoing mental health support from care managers, including support in using digital tools. The needs of patients and care managers may be so different that meeting both through the same tools represents a substantial challenge, and could require altering these professionals' roles in mental health support.
AHRQ-funded; HS028003.
Citation: Kornfield R, Lattie EG, Nicholas J .
"Our job is to be so temporary": designing digital tools that meet the needs of care managers and their patients with mental health concerns.
Proc ACM Hum Comput Interact 2023 Oct; 7(CSCW2):302. doi: 10.1145/3610093..
Keywords: Behavioral Health, Health Information Technology (HIT), Care Coordination
Anderson AJ, Noyes K, Hewner S
Expanding the evidence for cross-sector collaboration in implementation science: creating a collaborative, cross-sector, interagency, multidisciplinary team to serve patients experiencing homelessness and medical complexity at hospital discharge.
This report discussed the challenges for implementing cross-sector collaboration (CSC). A recuperative care collaborative in Buffalo, NY, provided care transition support at an acute care hospital discharge via a medical respite program for people who had experienced homelessness. Using the Expert Recommendations for Implementing Change (ERIC) framework and feedback from the cross-sector collaborative team, implementation strategies were derived from three validated ERIC implementation strategy clusters: development of stakeholder relationships, use of evaluative and iterative strategies, and changes to infrastructure. The authors concluded that future research would address external organizational influences and emphasize CSC as central to interventions.
AHRQ-funded; HS028000.
Citation: Anderson AJ, Noyes K, Hewner S .
Expanding the evidence for cross-sector collaboration in implementation science: creating a collaborative, cross-sector, interagency, multidisciplinary team to serve patients experiencing homelessness and medical complexity at hospital discharge.
Front Health Serv 2023 Sep 8; 3:1124054. doi: 10.3389/frhs.2023.1124054..
Keywords: Hospital Discharge, Chronic Conditions, Vulnerable Populations, Care Coordination, Transitions of Care
Parikh K, Richmond M, Lee M
Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma.
The purpose of this study was to evaluate a multi-component hospital-to-home (H2H) transition program for children hospitalized with an asthma exacerbation. A pilot prospective randomized clinical trial of guideline-based asthma care with and without a patient-centered multi-component H2H program was conducted among children enrolled in K-8(th) grade on Medicaid hospitalized for an asthma exacerbation. The investigators concluded that the pilot data suggested that comprehensive care coordination initiated during the inpatient stay was feasible and acceptable.
AHRQ-funded; HS024554.
Citation: Parikh K, Richmond M, Lee M .
Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma.
J Asthma 2021 Oct;58(10):1384-94. doi: 10.1080/02770903.2020.1795877..
Keywords: Children/Adolescents, Patient-Centered Healthcare, Transitions of Care, Asthma, Hospital Discharge, Care Coordination, Chronic Conditions
Hou Y, Bushnell CD, Duncan PW
Hospital to home transition for patients with stroke under bundled payments.
In this paper, the authors describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. They concluded that ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.
AHRQ-funded; R01 HS025723.
Citation: Hou Y, Bushnell CD, Duncan PW .
Hospital to home transition for patients with stroke under bundled payments.
Arch Phys Med Rehabil 2021 Aug;102(8):1658-64. doi: 10.1016/j.apmr.2021.03.010..
Keywords: Transitions of Care, Stroke, Cardiovascular Conditions, Care Coordination
Okado I, Pagano I, Cassel K
Perceptions of care coordination in cancer patient-family caregiver dyads.
The authors examined cancer patients and their family caregivers' perspectives of care coordination (CC) using a dyadic research design. They found that a subgroup of family caregivers reported poorer perception of CC than patients, suggesting that those family caregivers and providers may benefit from intervention. They concluded that further understanding of patient-family caregiver dyads' perspectives of CC can inform development of strategies to integrate family caregivers into the cancer care team, develop effective CC interventions for family caregivers, and contribute to improved quality and value of cancer care.
AHRQ-funded; HS027286.
Citation: Okado I, Pagano I, Cassel K .
Perceptions of care coordination in cancer patient-family caregiver dyads.
Support Care Cancer 2021 May;29(5):2645-52. doi: 10.1007/s00520-020-05764-8..
Keywords: Cancer, Caregiving, Care Coordination, Quality of Care
Kuo YF, Agrawal P, Chou LN
Assessing association between team structure and health outcome and cost by social network analysis.
Researchers sought to assess the impact of team structure composition and degree of collaboration among various providers on process and outcomes of primary care. Their findings showed that highly connected primary care practices with high collaborative care and less top-down MD-centered authority have lower odds of hospitalization, fewer emergency room admissions, and lower total spending. They concluded that these findings likely reflect better communication and more coordinated care of older patients.
AHRQ-funded; HS020642.
Citation: Kuo YF, Agrawal P, Chou LN .
Assessing association between team structure and health outcome and cost by social network analysis.
J Am Geriatr Soc 2021 Apr;69(4):946-54. doi: 10.1111/jgs.16962..
Keywords: Elderly, Teams, Healthcare Delivery, Primary Care, Primary Care: Models of Care, Care Coordination
Feinberg E, Kuhn J, Eilenberg JS
Improving family navigation for children with autism: a comparison of two pilot randomized controlled trials.
This study looked at impacts of a modification to a pilot program called Family Navigation to help low-income, minority children needing autism-related diagnostic services receive those services. An advisory group recommended modifications to recruitment criteria and study conditions. 40 parent-child dyad participants were randomized between the two pilots to receive usual care (UC) or modified FN. Participant enrollment, satisfaction with clinical care, and timely completion of the diagnostic assessment were compared. Recruitment improved significantly with the modified protocol (4.8% vs. 19.5%) and no participants were excluded from study enrollment compared to the first pilot (43.6%). Families in the second pilot were more likely to complete diagnostic assessment and report greater satisfaction with clinical care.
AHRQ-funded; HS022155; HS022242.
Citation: Feinberg E, Kuhn J, Eilenberg JS .
Improving family navigation for children with autism: a comparison of two pilot randomized controlled trials.
Acad Pediatr 2021 Mar;21(2):265-71. doi: 10.1016/j.acap.2020.04.007..
Keywords: Children/Adolescents, Autism, Patient-Centered Healthcare, Care Coordination, Racial and Ethnic Minorities, Low-Income, Patient and Family Engagement, Chronic Conditions
Ozkaynak M, Valdez R, Hannah K
Understanding gaps between daily living and clinical settings in chronic disease management: qualitative study.
This study’s objective was to characterize gaps from the patient’s perspective between health-related activities across home-based and clinical settings in the management of chronic conditions. Patients were recruited from an anticoagulation clinic of an urban, western mountain system and primary interviews were conducted with 39 patients and 4 providers. The causes of gaps included clinician recommendations not fitting into patients’ daily routines; recommendations not fitting into a patients’ living contexts; and no information transfer across settings. Consequences of these gaps included increased cognitive and physical workload on the patient, poor patient satisfaction, and compromised adherence to the therapy plan.
AHRQ-funded; HS024092.
Citation: Ozkaynak M, Valdez R, Hannah K .
Understanding gaps between daily living and clinical settings in chronic disease management: qualitative study.
J Med Internet Res 2021 Feb 25;23(2):e17590. doi: 10.2196/17590..
Keywords: Chronic Conditions, Care Management, Care Coordination, Patient Self-Management, Health Information Technology (HIT)
Sather J, Littauer R, Finn E
A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage.
Regionalization of care has increased interhospital transfers (IHTs) of nontraumatic intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) to specialized centers yet exposes patients to the latent risks inherent to IHT. In this study, the researchers examined how a multimodal quality improvement intervention affected quality and safety measures for patients with ICH or SAH exposed to IHT.
AHRQ-funded; HS023554.
Citation: Sather J, Littauer R, Finn E .
A multimodal intervention to improve the quality and safety of interhospital care transitions for nontraumatic intracerebral and subarachnoid hemorrhage.
Jt Comm J Qual Patient Saf 2021 Feb;47(2):99-106. doi: 10.1016/j.jcjq.2020.10.003..
Keywords: Transitions of Care, Hospitals, Patient Safety, Quality Improvement, Quality of Care, Care Coordination
Wang G, Wignall J, Kinard D
An implementation model for managing cloud-based longitudinal care plans for children with medical complexity.
In this study, the investigators aimed to iteratively refine an implementation model for managing cloud-based longitudinal care plans (LCPs) for children with medical complexity (CMC). They conducted iterative 1-on-1 design sessions with CMC caregivers (ie, parents/legal guardians) and providers between August 2017 and March 2019. The investigators concluded that utilizing the management strategies, described in the article, when implementing cloud-based LCPs had the potential to improve team-based care across settings.
AHRQ-funded; HS024299.
Citation: Wang G, Wignall J, Kinard D .
An implementation model for managing cloud-based longitudinal care plans for children with medical complexity.
J Am Med Inform Assoc 2021 Jan 15;28(1):23-32. doi: 10.1093/jamia/ocaa207..
Keywords: Children/Adolescents, Implementation, Chronic Conditions, Care Management, Care Coordination, Health Information Exchange (HIE), Health Information Technology (HIT), Teams
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)