National Healthcare Quality and Disparities Report
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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
26 to 50 of 104 Research Studies DisplayedOrtiz D, Meagher AD, Lindroth H
A trauma medical home, evaluating collaborative care for the older injured patient: study protocol for a randomized controlled trial.
It is estimated that 55 million adults will be 65 years and older in the USA by 2020. These older adults are at increased risk for injury and their recovery is multi-faceted. A collaborative care model may improve psychological and functional outcomes of the non-neurologically impaired older trauma patient and reduce health care costs. The investigators discussed the proposed study protocol which would evaluate a collaborative care model to help maximize psychological and functional recovery for non-neurologically injured older patients at four level one trauma centers in the Midwest.
AHRQ-funded; HS026390.
Citation: Ortiz D, Meagher AD, Lindroth H .
A trauma medical home, evaluating collaborative care for the older injured patient: study protocol for a randomized controlled trial.
Trials 2020 Jul 16;21(1):655. doi: 10.1186/s13063-020-04582-x..
Keywords: Elderly, Patient-Centered Healthcare, Injuries and Wounds, Care Coordination, Nursing Homes, Care Management
Amar-Dolan LG, Horn MH, O'Connell B B
"This is how hard it is". family experience of hospital-to-home transition with a tracheostomy.
This study explores the experience of family caregivers of children and young adults with a tracheostomy during the transition from hospital to home care. Researchers sought to identify the specific unmet needs of families to direct future interventions. Using semi-structured interviews, they found a need for family-centered discharge processes including coordination of care and teaching focused on emergency preparedness.
AHRQ-funded; HS000063.
Citation: Amar-Dolan LG, Horn MH, O'Connell B B .
"This is how hard it is". family experience of hospital-to-home transition with a tracheostomy.
Ann Am Thorac Soc 2020 Jul;17(7):860-68. doi: 10.1513/AnnalsATS.201910-780OC..
Keywords: Transitions of Care, Home Healthcare, Caregiving, Patient Experience, Care Coordination, Hospital Discharge, Hospitals, Children/Adolescents, Patient-Centered Healthcare
Campbell Britton M, Petersen-Pickett J, Hodshon B
Mapping the care transition from hospital to skilled nursing facility.
Researchers used process mapping to illustrate the sequence of events involved with hospital discharge and admission to a skilled nursing facility (SNF). These transitions are often associated with breakdowns in communication that may place patients at risk for adverse events. A quality improvement (QI) team worked with frontline staff at an academic medical center and two local SNFs in the northeastern United States. The final process map included care management, medicine, nursing, admissions and physical therapy service staff. The process map showed numerous activities that need to be coordinated between care teams, and highlighted specific opportunities for improving communication between different teams.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Petersen-Pickett J, Hodshon B .
Mapping the care transition from hospital to skilled nursing facility.
J Eval Clin Pract 2020 Jun;26(3):786-90. doi: 10.1111/jep.13238..
Keywords: Transitions of Care, Care Coordination, Quality Improvement, Communication, Hospital Discharge, Hospitals, Nursing Homes, Quality of Care
Nembhard IM, Buta E, Lee YSH
A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers.
The authors assessed effects of adding care coordination formally to nurses’ roles on care experiences of high-risk patients and clinician teamwork during the first 6 months of use. They conducted a quasi-experimental study in which changes in staff and patient experiences at six community health center practice locations that introduced the added-role approach for high-risk patients were compared to changes in six locations without the program in the same health system. They found that there were some positive effects of adding care coordination to nurses' role within 6 months of implementation, suggesting value in this improvement strategy. They concluded that addressing compatibility between coordination and other job demands is important when implementing this approach to coordination.
AHRQ-funded; HS016978.
Citation: Nembhard IM, Buta E, Lee YSH .
A quasi-experiment assessing the six-months effects of a nurse care coordination program on patient care experiences and clinician teamwork in community health centers.
BMC Health Serv Res 2020 Feb 24;20(1):137. doi: 10.1186/s12913-020-4986-0..
Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Care Coordination, Nursing, Patient Experience, Community-Based Practice, Patient-Centered Healthcare, Ambulatory Care and Surgery, Teams
Heeringa J, Mutti A, Furukawa MF
AHRQ Author: Furukawa MF
Horizontal and vertical integration of health care providers: a framework for understanding various provider organizational structures.
The authors conducted a narrative review of 10 years of literature to identify definitional components of key organizational structures in the United States. They found that U.S. policymakers seek to promote provider integration and coordination. They conclude that emerging evidence suggested that organizational structures, composition, and other characteristics influence cost and quality performance. They recommend future research to examine systematically the role of organizational structure in cost and quality outcomes.
AHRQ-authored; AHRQ-funded.
Citation: Heeringa J, Mutti A, Furukawa MF .
Horizontal and vertical integration of health care providers: a framework for understanding various provider organizational structures.
Int J Integr Care 2020 Jan 20;20(1):2. doi: 10.5334/ijic.4635.
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Keywords: Health Systems, Healthcare Delivery, Patient-Centered Healthcare, Care Coordination, Organizational Change, Policy
Derrett S, Gunter KE, Samaranayaka A
Development and testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey.
The authors developed and tested a 21-item questionnaire titled Provider and Staff Perceptions of Integrated Care Survey. The questionnaire was sent to 2,936 providers and staff at 100 federally qualified health centers and other clinics in Midwestern U.S. States, of which 2,604 were deemed eligible. Four mailings were conducted with a 30% response rate from 97 health centers. Four latent factors were suggested: Teams and Care Continuity, Patient Centeredness, Coordination with External Providers, and Coordination with Community Resources.
AHRQ-funded; HS000084.
Citation: Derrett S, Gunter KE, Samaranayaka A .
Development and testing of the Provider and Staff Perceptions of Integrated Care (PSPIC) Survey.
Med Care Res Rev 2019 Dec;76(6):807-29. doi: 10.1177/1077558717745936..
Keywords: Provider, Care Coordination, Patient-Centered Healthcare, Teams
Rosa TD, Possin KL, Bernstein A
Variations in costs of a collaborative care model for dementia.
Care coordination programs can improve patient outcomes and decrease healthcare expenditures; however, implementation costs are poorly understood. In this study, the investigators evaluated the direct costs of implementing a collaborative dementia care program. They found that care team navigators caseload was an important driver of service cost. They provide strategies for maximizing caseload without sacrificing quality of care and discuss current barriers to broad implementation that can inform new reimbursement policies.
AHRQ-funded; HS022241.
Citation: Rosa TD, Possin KL, Bernstein A .
Variations in costs of a collaborative care model for dementia.
J Am Geriatr Soc 2019 Dec;67(12):2628-33. doi: 10.1111/jgs.16076.
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Keywords: Dementia, Healthcare Costs, Care Coordination, Elderly, Care Management, Implementation, Teams
Fleming MD, Guo C, Knox M
Impact of social needs case management on use of medical and behavioral health services: secondary analysis of a randomized controlled trial.
This research letter describes a secondary analysis that was conducted of a randomized encouragement study that assigned Medicaid beneficiaries with high risk for acute care use to social needs case management or to be administratively observed in the control group from August 2017 through December 2018. These services connect patients to resources such as food assistance, housing, transportation, or income benefits in addition to facilitating access to health care and behavioral health services. The study group included adults 18 years or older, who are residents of Contra Costa County in California, and enrolled in full-scope Medicaid. The case management enrollees were assigned to a case manager who assessed their needs, created a patient-centered care plan, and provided ongoing support including community resource referrals, coordination with primary care providers, and collaboration on applications for public benefits. Case managers had diverse backgrounds and included public health nurses, social workers, substance misuse counselors, mental health clinicians, homeless service specialists, and community health workers. Case management was offered either in-person or by remote telephonic services for 1 year. About 40% (n = 8577) of enrolled patients used the services. There were 21,422 intervention group enrollments and 22,839 in the weighted control group. The intervention group had significantly higher rates of primary care visits compared with the control group. No differences were found between the treatment groups for specialty care visits, behavioral health visits, psychiatric emergency visits, or jail intakes.
AHRQ-funded; HS027648.
Citation: Fleming MD, Guo C, Knox M .
Impact of social needs case management on use of medical and behavioral health services: secondary analysis of a randomized controlled trial.
Ann Intern Med 2023 Aug; 176(8):1139-41. doi: 10.7326/m23-0876..
Keywords: Medicaid, Vulnerable Populations, Social Determinants of Health, Care Management, Care Coordination
Sobotka SA, Lynch E, Quinn MT
Unmet respite needs of children with medical technology dependence.
Children with medical technology dependency (MTD) require a medical device to compensate for a vital body function and substantial nursing care. As such, they require constant high-level supervision. Respite care provides caregivers with a temporary break, and is associated with reduced stress; however, there are often barriers. The study utilizes mixed methodology with the National Survey of Children with Special Health Care Needs (NS-CSHCN) and semistructured interviews with state-wide care coordinators to understand the gap for respite care services.
AHRQ-funded; HS023007.
Citation: Sobotka SA, Lynch E, Quinn MT .
Unmet respite needs of children with medical technology dependence.
Clin Pediatr 2019 Oct;58(11-12):1175-86. doi: 10.1177/0009922819870251..
Keywords: Children/Adolescents, Medical Devices, Disabilities, Caregiving, Home Healthcare, Care Coordination
Timbie JW, Kranz AM, Mahmud A
Federally qualified health center strategies for integrating care with hospitals and their association with measures of communication.
Federally qualified health centers have aligned clinical services and systems with local hospitals, but little is known about the specific care integration strategies health centers use or their impact on care. In this study, a research team examined the use of strategies by health centers to integrate care with hospitals and emergency departments (EDs) and their association with performance on measures of health center-hospital communication.
AHRQ-funded; HS024067.
Citation: Timbie JW, Kranz AM, Mahmud A .
Federally qualified health center strategies for integrating care with hospitals and their association with measures of communication.
Jt Comm J Qual Patient Saf 2019 Sep;45(9):620-28. doi: 10.1016/j.jcjq.2019.06.004..
Keywords: Patient-Centered Healthcare, Patient-Centered Outcomes Research, Hospitals, Communication, Emergency Department, Care Coordination, Healthcare Delivery
Campbell Britton M, Hodshon B, Chaudhry SI
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
This study focused on increasing better communication during transfers from hospitals and skilled nursing facilities (SNFs). Warm handoffs between hospital and SNF physicians was implemented. Participation in warm handoffs gradually increased – starting at 15.78% in stage 1 and increasing to 46.89% in stage 3. A total of 2417 patient discharges were included in this study.
AHRQ-funded; HS023554.
Citation: Campbell Britton M, Hodshon B, Chaudhry SI .
Implementing a warm handoff between hospital and skilled nursing facility clinicians.
J Patient Saf 2019 Sep;15(3):198-204. doi: 10.1097/pts.0000000000000529..
Keywords: Communication, Patient Safety, Hospital Discharge, Transitions of Care, Care Coordination, Hospitals, Nursing Homes
Bierman AS
AHRQ Author: Bierman AS
Preventing and managing multimorbidity by integrating behavioral health and primary care.
People with multimorbidity are especially challenged in navigating fragmented health systems designed to treat diseases rather than people. The harms associated with this fragmentation, such as adverse events resulting from conflicting treatments and increased costs, have been well documented. As a result, there have been renewed calls for more patient-centered care, with a particular emphasis on the importance of the integration of primary care and behavioral health as fundamental for achieving this goal. This paper discusses preventing and managing multimorbidity by integrating behavioral health and primary care.
AHRQ author - Bierman
Citation: Bierman AS .
Preventing and managing multimorbidity by integrating behavioral health and primary care.
Health Psychol 2019 Sep;38(9):851-54. doi: 10.1037/hea0000787..
Keywords: Care Coordination, Healthcare Delivery, Behavioral Health, Patient-Centered Healthcare, Primary Care
Zachrison KS, Dhand A, Schwamm LH
A network approach to stroke systems of care.
This study provided a network analysis of stroke systems of care. Stroke patients are increasing transferred between hospitals to receive higher levels of care, but coordination and triage of these patients remains a challenge. The network analysis provides an understanding of the central hubs, the change of network structure over time, and the dissemination of innovations.
AHRQ-funded; HS024561.
Citation: Zachrison KS, Dhand A, Schwamm LH .
A network approach to stroke systems of care.
Circ Cardiovasc Qual Outcomes 2019 Aug;12(8):e005526. doi: 10.1161/circoutcomes.119.005526..
Keywords: Stroke, Care Coordination, Transitions of Care, Care Management, Cardiovascular Conditions, Hospitals
Wooldridge A, Carayon P, Hoonakker P
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Trauma is the leading cause of disability and death in children and young adults in the US. While much is known about the medical aspects of inpatient pediatric trauma care, not much is known about the processes and roles involved in in-hospital care. Using human factors engineering (HFE) methods, the investigators combined interview, archival document and trauma registry data to describe how intra-hospital care transitions affect process and team complexity.
AHRQ-funded; HS023837.
Citation: Wooldridge A, Carayon P, Hoonakker P .
Complexity of the pediatric trauma care process: implications for multi-level awareness.
Cogn Technol Work 2019 Aug;21(3):397-416. doi: 10.1007/s10111-018-0520-0..
Keywords: Care Coordination, Children/Adolescents, Critical Care, Health Services Research (HSR), Healthcare Delivery, Inpatient Care, Patient Safety, Teams, Trauma, Young Adults
Davis MM, Gunn R, Pham R
Key collaborative factors when Medicaid Accountable Care Organizations work with primary care clinics to improve colorectal cancer screening: relationships, data, and quality improvement infrastructure.
This study focused on ways that Medicaid Accountable Care Organizations (ACOs) are implementing interventions with primary care clinics to improve colorectal cancer screening. The researchers conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics. They focused on interventions that reduced structural barriers (12 ACOs), delivered provider assessment and feedback (11 ACOs), and provided patient reminders (7 ACOs). There was an unintended consequence of potential exclusion of smaller clinics and metric focus and fatigue.
AHRQ-funded; HS022981.
Citation: Davis MM, Gunn R, Pham R .
Key collaborative factors when Medicaid Accountable Care Organizations work with primary care clinics to improve colorectal cancer screening: relationships, data, and quality improvement infrastructure.
Prev Chronic Dis 2019 Aug 15;16:E107. doi: 10.5888/pcd16.180395..
Keywords: Primary Care: Models of Care, Primary Care, Screening, Colonoscopy, Cancer: Colorectal Cancer, Cancer, Quality Improvement, Quality of Care, Care Coordination, Patient-Centered Healthcare
Wyatt DL
AHRQ Author: Wyatt DL
Employing technology to make care transitions safer.
This commentary discusses the potential for errors in patient handoffs; important information about medications and instructions regarding patient care may be overlooked when the patient is referred to special care, moved to a new hospital setting, or discharged. The problem is especially acute for patients with multiple chronic conditions who often undergo frequent transitions to new care settings and healthcare providers. The author describes AHRQ’s funding opportunities for health information technology interventions that aim to improve communication and coordination during care transitions, such as location-based smartphone alerts, a patient-centered discharge toolkit, and a ‘smart pillbox’ electronic medication adherence reporting project.
AHRQ-authored.
Citation: Wyatt DL .
Employing technology to make care transitions safer.
J Nurs Care Qual 2019 Jul/Sep;34(3):185-88. doi: 10.1097/ncq.0000000000000417..
Keywords: Adverse Events, Care Coordination, Chronic Conditions, Communication, Health Information Technology (HIT), Healthcare Delivery, Hospital Discharge, Medical Errors, Medication, Patient Safety, Transitions of Care
Hass Z, Woodhouse M, Grabowski DC
Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents.
This study evaluated the Minnesota Return to Community Initiative (RTCI) program which facilitates community discharge of non-Medicaid nursing home residents. It was implemented statewide without a control group. The program assists with discharge planning, transitioning to the community, and postdischarge follow-up. Results showed the program increased discharge rates by an estimated 11 percent. Success increased with time as nursing home facilities increased their participation.
AHRQ-funded; HS020224.
Citation: Hass Z, Woodhouse M, Grabowski DC .
Assessing the impact of Minnesota's return to community initiative for newly admitted nursing home residents.
Health Serv Res 2019 Jun;54(3):555-63. doi: 10.1111/1475-6773.13118..
Keywords: Care Coordination, Long-Term Care, Nursing Homes, Transitions of Care
Holmes E, Thompson D, Michell D
An inpatient HIV support nurse to promote engagement in outpatient HIV care.
In this paper, the investigators describe an inpatient HIV support nurse to promote engagement in outpatient HIV care. It provides two case reports and a discussion. The investigators indicate that their hospital has employed an RN specializing in HIV care coordination for more than a decade on their dedicated HIV unit and has recently created a position to extend this work to PLWH who have been admitted to the 42 other adult units in their hospital.
AHRQ-funded; R01 HS024079.
Citation: Holmes E, Thompson D, Michell D .
An inpatient HIV support nurse to promote engagement in outpatient HIV care.
J Assoc Nurses AIDS Care 2019 Mar-Apr;30(2):245-48. doi: 10.1097/jnc.0000000000000017..
Keywords: Human Immunodeficiency Virus (HIV), Patient and Family Engagement, Care Coordination, Nursing, Healthcare Delivery
Lin SC, Regenbogen SE, Hollingsworth JM
Coordination of care around surgery for colon cancer: insights from national patterns of physician encounters with Medicare beneficiaries.
This study researched the coordination of care before and after surgery for colon cancer patients using data from Medicare A and B records. There were quite a number of different combinations of care providers both preoperative and postoperative. Larger urban teaching hospitals had the most combinations in all phases.
AHRQ-funded; HS024525; HS024728.
Citation: Lin SC, Regenbogen SE, Hollingsworth JM .
Coordination of care around surgery for colon cancer: insights from national patterns of physician encounters with Medicare beneficiaries.
J Oncol Pract 2019 Feb;15(2):e110-e21. doi: 10.1200/jop.18.00228..
Keywords: Cancer, Cancer: Colorectal Cancer, Care Coordination, Medicare, Surgery
Gupta S, Zengul FD, Davlyatov GK
Reduction in hospitals' readmission rates: role of hospital-based skilled nursing facilities.
The purpose of this study was to examine the association between hospital-based skilled nursing facilities (HBSNFs) and hospitals' readmission rates. Data sources included the American Hospital Association Annual Survey, Area Health Resources Files, CMS Medicare cost reports and Hospital Compare. Results showed that the presence of HBSNFs was associated with lower readmission rates for acute myocardial infarction and pneumonia. Further, higher skilled nursing facilities to hospitals ratio were associated with lower readmission rates.
AHRQ-funded; HS023345.
Citation: Gupta S, Zengul FD, Davlyatov GK .
Reduction in hospitals' readmission rates: role of hospital-based skilled nursing facilities.
Inquiry 2019 Jan-Dec;56:46958018817994. doi: 10.1177/0046958018817994..
Keywords: Hospital Readmissions, Transitions of Care, Care Coordination, Hospitals, Quality Indicators (QIs), Quality Measures, Quality of Care
Phillippi JC, Holley SL, Thompson JL
A planning checklist for interprofessional consultations for women in midwifery care.
This article describes a planning checklist tool designed by using feedback from women, nurses, midwives, and physicians, to improve communication within one health system and to develop a community-engaged approach for the care of women who began care with midwives but developed risks for poor perinatal outcomes. In feasibility testing, the checklist provided a prompt to generate a comprehensive plan for maternity care and to elucidate the rationale for interventions to women and future health care providers. In post-implementation interviews, women said they were pleased with the information they received, and nurses, midwives, and physicians were positive about improved communication. The article details the creation, implementation, and qualitative evaluation of the planning checklist.
AHRQ-funded; HS024733.
Citation: Phillippi JC, Holley SL, Thompson JL .
A planning checklist for interprofessional consultations for women in midwifery care.
J Midwifery Womens Health 2019 Jan;64(1):98-103. doi: 10.1111/jmwh.12900..
Keywords: Care Coordination, Care Management, Communication, Maternal Care, Pregnancy, Women
Durojaiye AB, McGeorge N, Kristen W
Characterizing the utilization of the problem list for pediatric trauma care.
The EHR problem list has the potential to support care coordination among the multidisciplinary care team that cares for pediatric trauma patients. To realize this potential, the need exists to ensure appropriate utilization by formulating acceptable usage and management policy. In this regard, understanding the prevailing utilization pattern is pivotal. To this end, in this study, the investigators analyzed EHR in tandem with trauma registry data at a Level I pediatric trauma center.
AHRQ-funded; HS023837.
Citation: Durojaiye AB, McGeorge N, Kristen W .
Characterizing the utilization of the problem list for pediatric trauma care.
AMIA Annu Symp Proc 2018 Dec 5;2018:404-12..
Keywords: Care Coordination, Children/Adolescents, Electronic Health Records (EHRs), Emergency Department, Health Information Technology (HIT), Hospitals, Registries, Trauma
Quintana Y, Fahy D, Crotty B
InfoSAGE: Supporting elders and families through online family networks.
With an increasingly elderly population, families are finding it increasingly challenging to coordinate care for their older family members. This paper reports on the findings of InfoSAGE, an online private social network that has tools for communication and care coordination for elders and their families.
AHRQ-funded; HS021495; HS024869.
Citation: Quintana Y, Fahy D, Crotty B .
InfoSAGE: Supporting elders and families through online family networks.
AMIA Annu Symp Proc 2018 Dec 5;2018:932-41..
Keywords: Elderly, Caregiving, Health Information Technology (HIT), Communication, Clinician-Patient Communication, Care Coordination
Senft 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