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Research Studies is a monthly compilation of research articles funded by AHRQ or authored by AHRQ researchers and recently published in journals or newsletters.
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1 to 25 of 100 Research Studies DisplayedAlagoz E, Saucke M, Arroyo N
Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.
This study’s objective was to understand the nature of and challenges to communication between referring (RP) and accepting (AP) providers transferring emergency general surgery (EGS) patients from the transfer center nurse’s (TCN) perspective. Worse outcomes have been shown to be experienced by transferred EGS patients than directly admitted patients. The authors interviewed 17 transfer center nurses (TCNs) at an academic medical center regarding (in)efficient and (in)effective communication between RPs and APs. The in-person interviews were recorded, transcribed and managed in NVivo. Four researchers developed a codebook, which was then co-coded with the transcripts. A consensus was developed to discuss emergency themes and arrive at higher-level concepts. Issues relating to ineffective communication included RPs that provided incomplete information because of a lack of necessary infrastructure, personnel, or technical knowledge; competing clinical demands; or a fear of the transfer request being rejected. Inefficient communication resulted from RPs being unfamiliar with the information APs expected and the lack of a structured process to share information and communication also failed when providers disagreed about the necessity of the transfer.
AHRQ-funded; HS025224.
Citation: Alagoz E, Saucke M, Arroyo N .
Communication during interhospital transfers of emergency general surgery patients: a qualitative study of challenges and opportunities.
J Patient Saf 2022 Oct 1;18(7):711-16. doi: 10.1097/pts.0000000000000979..
Keywords: Care Coordination, Communication, Transitions of Care, Surgery
Norton JM, Ip A, Ruggiano N
Assessing progress toward the vision of a comprehensive, shared electronic care plan: scoping review.
People with multiple chronic conditions often receive care from a broad array of clinicians across multiple health care settings, making it difficult to share care plans between those facilities and providers. One method for possibly improving care for those individuals is through the development and use of comprehensive, shared, electronic care (e-care) plans. The purpose of the study was to review existing e-care plans and related initiatives that could be utilized to develop a comprehensive, shared e-care plan, and facilitate the National Institutes of Health and Agency for Healthcare Research and Quality joint initiative’s creation of e-care planning tools for people with multiple chronic conditions. The researchers conducted a review of literature from 2015-2020, as well as interviews of expert informants to identify information missing from the literature search. The study identified 7 different interventions for e-care plans and 3 different projects for health care data standards, all of which included elements which could be utilized to further the goals of developing a comprehensive, shared e-care plan. The study concluded that while none of the existing interventions met all the optimal e-care plan criteria for people with multiple chronic conditions, each plan included the infrastructure necessary to progress toward that goal. The researchers reported that gaps must first be addressed, but that a comprehensive, shared e-care plan can improve care coordination across multiple care settings and clinicians.
AHRQ-authored.
Citation: Norton JM, Ip A, Ruggiano N .
Assessing progress toward the vision of a comprehensive, shared electronic care plan: scoping review.
J Med Internet Res 2022 Jun 10;24(6):e36569. doi: 10.2196/36569..
Keywords: Chronic Conditions, Care Coordination, Electronic Health Records (EHRs), Health Information Technology (HIT), Healthcare Delivery, Health Information Exchange (HIE)
Valley TS, Schutz A, Peltan ID
Organization of outpatient care after COVID-19 hospitalization.
The purpose of this study was to describe post-discharge care delivery for patients with postacute sequelae of COVID-19 (PASC) across a large network of US academic and community hospitals. Beginning in July, 2021, the researchers surveyed 47 hospitals which were participating in the National Heart, Lung, and Blood Institute Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury (PETAL Network.) Surveys were completed by physicians, hospital administrators, social workers, research staff or other clinicians over an 8-week period, and data from the 2019 American Hospital Association annual survey database were used to describe the hospitals. The study found that 79% (37) of the responding hospitals provided COVID-specific discharge information to patients hospitalized with COVID-19. Only 26% of hospitals provided discharge information that included potential symptoms or impairments of postacute sequelae of COVID-19. Seventy percent (33) had a PASC clinic (a postdischarge outpatient clinic designed specifically for patients with COVID). Hospitals without PASC clinics were more likely to be located in a ZIP code with a higher Medicare population and a median annual income lower than $40,000, and were also more likely to be smaller, for-profit hospitals. The researchers identified several core areas for possible improvements in PASC care, including: examining the impact of PASC clinics on patient outcomes; assessing the extent to which the pathophysiology and management of PASC differ from sequelae of other infections and syndromes; and exploring whether an inability to systematically identify patients for PASC care may result in an inability for some patients to receive needed care. The researchers concluded that PASC clinics may offer opportunities to coordinate care and serve as an opportunity for making iterative gains in knowledge about PASC clinics and related models and processes and their effectiveness in improving longer-term patient-centered outcomes for survivors of COVID-19.
AHRQ-funded; HS028038.
Citation: Valley TS, Schutz A, Peltan ID .
Organization of outpatient care after COVID-19 hospitalization.
Chest 2022 Jun;161(6):1485-89. doi: 10.1016/j.chest.2022.01.034..
Keywords: COVID-19, Ambulatory Care and Surgery, Hospitalization, Care Coordination, Healthcare Delivery
Usher MC, Tignanelli CJ, Hilliard B
Responding to COVID-19 through interhospital resource coordination: a mixed-methods evaluation
Researchers sought to describe a novel hospital system approach to managing the COVID-19 pandemic, including multihospital coordination capability and transfer of COVID-19 patients to a single, dedicated hospital. They found that, with standardized communication, interhospital transfers were a safe and effective method of cohorting COVID-19 patients, were well-received by health care providers, and had the potential to improve care quality.
AHRQ-funded; HS026379; HS026732.
Citation: Usher MC, Tignanelli CJ, Hilliard B .
Responding to COVID-19 through interhospital resource coordination: a mixed-methods evaluation
J Patient Saf 2022 Jun 1;18(4):287-94. doi: 10.1097/pts.0000000000000916..
Keywords: COVID-19, Hospitals, Healthcare Delivery, Public Health, Care Coordination, Transitions of Care
Everson J, Adler-Milstein JR, Hollingsworth JM
Dispersion in the hospital network of shared patients is associated with less efficient care.
The purpose of this study was to examine the level of distribution of patient-sharing networks across U.S. hospitals and its relationship with 3 measures of care delivered by hospitals that were likely to relate to coordination. The researchers utilized data from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common, and then calculated a measure of dispersion for each hospital. The relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates were then estimated. The study reported that hospitals with more dispersed networks had greater spending rates but not higher admission rates or slower ED processes. Among hospitals with less resources, more dispersion was associated with higher readmission rates and slower ED processes. The researchers concluded that dispersed interhospital networks create difficulties in coordinating patients who are treated at multiple hospitals, and that the structure of patient-sharing networks may be an overlooked factor that influences the delivery of care in health care organizations.
AHRQ-funded; HS026395, HS024525, HS024728, HS024454.
Citation: Everson J, Adler-Milstein JR, Hollingsworth JM .
Dispersion in the hospital network of shared patients is associated with less efficient care.
Health Care Manage Rev 2022 Apr-Jun;47(2):88-99. doi: 10.1097/hmr.0000000000000295..
Keywords: Medicare, Hospitals, Care Coordination, Healthcare Delivery
Ahern J, Singer S, Bhanja A
Considering dentists within the healthcare team: a cross-sectional, multi-state analysis of primary care provider and staff perspectives.
The authors used novel survey data to examine the extent to which primary care providers, other providers, and staff consider dentists part of the healthcare team, and assessed associated practice and individual characteristics. Their findings indicated that dentists are frequently not considered part of the healthcare team in primary care settings. Further, varied responses within practices suggested that provider and staff perceptions may pose challenges to integrating dentists into primary care. Respondents in practices with more integrated diabetes care management processes were more likely to consider dentists as part of the healthcare team, reflecting dental care recommendations made by the American Diabetes Association.
AHRQ-funded; HS024067.
Citation: Ahern J, Singer S, Bhanja A .
Considering dentists within the healthcare team: a cross-sectional, multi-state analysis of primary care provider and staff perspectives.
J Gen Intern Med 2022 Jan;37(1):246-48. doi: 10.1007/s11606-020-06564-w..
Keywords: Primary Care, Provider: Health Personnel, Patient-Centered Healthcare, Care Coordination
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, Rehabilitation, 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
Desai AD, Wang G, Wignall J
User-centered design of a longitudinal care plan for children with medical complexity.
This study’s goal was to determine content priorities and design preferences for a longitudinal care plan (LCP) among caregivers and healthcare providers who care for children with complex medical conditions (CMC) in acute care settings. Thirty iterative one-on-one design sessions with 10 caregivers and 20 providers were conducted. There was high within-group variability in content preferences among caregivers compared to provider groups. The authors identified 6 design preferences: a familiar yet customizable layout, a problem-based organization schema, linked content between sections, a table layout for most sections, a balance between unstructured and structured data fields, and use of family-centered terminology.
AHRQ-funded; HS024299.
Citation: Desai AD, Wang G, Wignall J .
User-centered design of a longitudinal care plan for children with medical complexity.
J Am Med Inform Assoc 2020 Dec 9;27(12):1860-70. doi: 10.1093/jamia/ocaa193..
Keywords: Children/Adolescents, Chronic Conditions, Electronic Health Records (EHRs), Health Information Technology (HIT), Care Coordination, Caregiving
Quigley DD, Qureshi N, Masarweh LA
Practice leaders report targeting several types of changes in care experienced by patients during patient-centered medical home transformation.
This study looked at how primary care practices implemented changes during the transition to becoming a patient-centered medical home (PCMH). The authors examined 105 primary care practice leader experiences during PCMH transformation using semi-structured interviews. Practices most commonly targeted changes in care coordination (30%), access to care (25%), and provider communication (24%). Reported areas for PCMH transformation were measured by Clinician & Group CAHPS, PCMH CAHPS, or supplemental CAHPS survey items, including team-based care (35%), providing more on-site services (28%), care management (22%), patient-centered culture (18%), and chronic condition health education (13%). Many PCMH changes are captured by CAHPS survey items, but some are not.
AHRQ-funded; HS025920.
Citation: Quigley DD, Qureshi N, Masarweh LA .
Practice leaders report targeting several types of changes in care experienced by patients during patient-centered medical home transformation.
J Patient Exp 2020 Dec;7(6):1509-18. doi: 10.1177/2374373520934231..
Keywords: Consumer Assessment of Healthcare Providers and Systems (CAHPS), Primary Care: Models of Care, Primary Care, Patient-Centered Healthcare, Patient Experience, Care Coordination, Quality Improvement, Quality of Care, Implementation
Guo F, Lin YL, Raji M
Processes and outcomes of diabetes mellitus care by different types of team primary care models.
This study compared processes and outcomes of care provided to older patients with diabetes by primary care teams composed of only primary care physicians (PCPs) versus team care that included nurse practitioners (NPs) or physician assistants (PAs). The authors studied 3,524 primary care practices identified via social network analysis and 306,741 patients aged 66 and older diagnosed with diabetes mellitus in or before 2015 from Medicare data. Outcomes looked for was more adherence to guideline-recommended care including eye examination, hemoglobin A1c test, and nephropathy monitoring. Preventable hospitalizations and high-risk medication prescribing rates were also measured. Patients in the team care practices received more guideline-recommended diabetes care than patients in PCP only teams. Patients in team care practices had a slightly higher likelihood of being prescribed high-risk medications. The likelihood of preventable hospitalizations was similar among all types of practices.
AHRQ-funded; HS020642.
Citation: Guo F, Lin YL, Raji M .
Processes and outcomes of diabetes mellitus care by different types of team primary care models.
PLoS One 2020 Nov 5;15(11):e0241516. doi: 10.1371/journal.pone.0241516..
Keywords: Elderly, Teams, Primary Care: Models of Care, Healthcare Delivery, Outcomes, Care Coordination, Practice Patterns
Lindly OJ, Martin AJ, Lally K
A profile of care coordination, missed school days, and unmet needs among Oregon children with special health care needs with behavioral and mental health conditions.
In order to inform Oregon's Title V needs assessment activities, researchers sought to characterize the state's subpopulation of children with special health care needs (CSHCN) with behavioral and mental health conditions (B/MHC) and to determine associations of care coordination with missed school days and unmet needs for this subpopulation. They found that among Oregon CSHCN with B/MHC, 48.9% missed 4 or more school days, 25% had one or more unmet health services need, and 14.8% had one or more unmet family support services need. They concluded that their approach to identify Oregon CSHCN with B/MHC may be adopted by other states endeavoring to improve health for this vulnerable subpopulation.
AHRQ-funded; HS000063.
Citation: Lindly OJ, Martin AJ, Lally K .
A profile of care coordination, missed school days, and unmet needs among Oregon children with special health care needs with behavioral and mental health conditions.
Community Ment Health J 2020 Nov;56(8):1571-80. doi: 10.1007/s10597-020-00609-4..
Keywords: Children/Adolescents, Disabilities, Behavioral Health, Care Coordination, Healthcare Delivery
Shannon EM, Schnipper JL, Mueller SK
Identifying racial/ethnic disparities in interhospital transfer: an observational study.
Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized. The purpose of this study was to evaluate the association between race/ethnicity and IHT. The investigators found that Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.
AHRQ-funded; HS023331.
Citation: Shannon EM, Schnipper JL, Mueller SK .
Identifying racial/ethnic disparities in interhospital transfer: an observational study.
J Gen Intern Med 2020 Oct;35(10):2939-46. doi: 10.1007/s11606-020-06046-z..
Keywords: Racial and Ethnic Minorities, Disparities, Transitions of Care, Hospitals, Care Coordination
Berry JG, Glaspy T, Eagan B
Pediatric complex care and surgery comanagement: preparation for spinal fusion.
This study assessed the impact of preoperative comanagement with complex care pediatricians (CCP) on children with neuromuscular scoliosis undergoing spinal fusion surgery. A chart review of 79 children aged 5-21 years undergoing spinal fusion Jan. 2014-June 2016 was conducted at a children’s hospital. Cerebral palsy (64%) was the most common neuromuscular condition with the mean age of surgery of 14 years. Thirty-nine children had a preoperative CCP evaluation a median 63 days before the preanesthesia visit. More organ systems were affected by coexisting conditions in children with CCP evaluation than those without an evaluation. The rate of last-minute care coordination activities required for surgical clearance as well as last-minute development of new preoperative plans were lower for children with CCP evaluation than those without.
AHRQ-funded; HS024453.
Citation: Berry JG, Glaspy T, Eagan B .
Pediatric complex care and surgery comanagement: preparation for spinal fusion.
J Child Health Care 2020 Sep;24(3):402-10. doi: 10.1177/1367493519864741..
Keywords: Children/Adolescents, Surgery, Care Management, Care Coordination
Callister C, Jones J, Schroeder S
Caregiver experiences of care coordination for recently discharged patients: a qualitative metasynthesis.
Caregivers of patients often provide key support for patients after hospitalization. This qualitative metasynthesis described caregiver perspectives about care coordination for patients discharged from the hospital. A literature search of Ovid Medline and CINAHL completed on May 23, 2018, identified 1,546 studies. Twelve articles were included in the final metasynthesis. Caregiver perspectives about care coordination were compiled into overall themes.
AHRQ-funded; HS024569.
Citation: Callister C, Jones J, Schroeder S .
Caregiver experiences of care coordination for recently discharged patients: a qualitative metasynthesis.
West J Nurs Res 2020 Aug;42(8):649-59. doi: 10.1177/0193945919880183..
Keywords: Caregiving, Care Coordination, Hospital Discharge, Home Healthcare
White EM, Kosar CM, Rahman M
Trends in hospitals and skilled nursing facilities sharing medical providers, 2008-16.
Hospitals and skilled nursing facilities (SNFs) face increasing pressure to improve care coordination and reduce unnecessary readmissions. One strategy to accomplish this is to share physicians and advanced practice clinicians, so that the same providers see patients in both settings. Using 2008-16 Medicare claims, the investigators found that as SNFs moved increasingly toward using SNF specialists, there was a steady decline in the number of facilities sharing medical providers and in the proportion of SNF primary care delivered by provider practices with both hospital and SNF clinicians (hospital-SNF practices).
AHRQ-funded; T32 HS000011.
Citation: White EM, Kosar CM, Rahman M .
Trends in hospitals and skilled nursing facilities sharing medical providers, 2008-16.
Health Aff 2020 Aug;39(8):1312-20. doi: 10.1377/hlthaff.2019.01502..
Keywords: Hospitals, Nursing Homes, Care Coordination, Healthcare Delivery
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.
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
