National Healthcare Quality and Disparities Report
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Topics
- Adverse Events (1)
- Ambulatory Care and Surgery (1)
- Behavioral Health (2)
- (-) Care Coordination (22)
- Caregiving (1)
- Children/Adolescents (4)
- Chronic Conditions (3)
- Clinician-Patient Communication (1)
- Communication (5)
- Community-Based Practice (1)
- COVID-19 (2)
- Critical Care (1)
- Disabilities (1)
- Elderly (4)
- Electronic Health Records (EHRs) (1)
- Emergency Department (1)
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- Health Information Technology (HIT) (5)
- Health Insurance (1)
- Health Services Research (HSR) (2)
- Health Systems (1)
- Hospital Discharge (2)
- Hospitalization (1)
- Hospitals (4)
- Human Immunodeficiency Virus (HIV) (1)
- Inpatient Care (1)
- Medical Errors (1)
- Medicare (1)
- Medication (1)
- Nursing (1)
- Nursing Homes (1)
- Organizational Change (1)
- Outcomes (2)
- Patient-Centered Healthcare (4)
- Patient-Centered Outcomes Research (1)
- Patient and Family Engagement (2)
- Patient Safety (2)
- Policy (1)
- Practice Patterns (1)
- Primary Care (2)
- Primary Care: Models of Care (2)
- Provider (1)
- Provider: Nurse (1)
- Public Health (1)
- Teams (3)
- Telehealth (1)
- Transitions of Care (3)
- Trauma (1)
- Young Adults (1)
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 22 of 22 Research Studies DisplayedNorton JM, Ip A, Ruggiano N
AHRQ Author: Camara DS, Hsiao CJ, Bierman AS
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
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
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
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
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
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
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
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
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
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
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
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
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)
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)
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
Khan A, Rogers JE, Forster CS
Communication and shared understanding between parents and resident-physicians at night.
The researchers studied communication breakdowns evidenced by lack of shared understanding between parents and night-team residents about the reason for admission and care plan. After conducting a prospective cohort study of 286 parents and 37 night-team senior residents, they found that parents and residents reported that they shared an understanding with one another about care plans in 86.0percent and 73.1 percent of cases, respectively.
AHRQ-funded; HS022986; HS000063.
Citation: Khan A, Rogers JE, Forster CS .
Communication and shared understanding between parents and resident-physicians at night.
Hosp Pediatr 2016 Jun;6(6):319-29. doi: 10.1542/hpeds.2015-0224.
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Keywords: Care Coordination, Healthcare Delivery, Communication, Patient and Family Engagement, Clinician-Patient Communication
Rundall TG, Wu FM, Lewis VA
Contributions of relational coordination to care management in accountable care organizations: views of managerial and clinical leaders.
The researchers identified the extent to which accountable care organization (ACO) leaders are aware of the dimensions of relational coordination and the ways these leaders believe the dimensions influenced care management practices in their organization. They found that ACO leaders mentioned four relational coordination dimensions: shared goals, frequency of communication, timeliness of communication, and problem solving communication. Their analysis identified ways leaders believed the four dimensions contributed to the development of care management, including contributions to standardization of care, patient engagement, coordination of care, and care planning.
AHRQ-funded; HS022241.
Citation: Rundall TG, Wu FM, Lewis VA .
Contributions of relational coordination to care management in accountable care organizations: views of managerial and clinical leaders.
Health Care Manage Rev 2016 Apr-Jun;41(2):88-100. doi: 10.1097/hmr.0000000000000064.
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Keywords: Care Coordination, Health Insurance, Healthcare Delivery, Communication
Friedman A, Howard J, Shaw EK
Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators' perspectives.
This is the first study describing experiences of care coordinators across the US from their own perspectives. It concluded that while all the barriers and facilitators were important to performing coordinators' roles, relationship building was key to effective care coordination, whether with clinicians, patients, or outside organizations.
AHRQ-funded; HS020682.
Citation: Friedman A, Howard J, Shaw EK .
Facilitators and barriers to care coordination in patient-centered medical homes (PCMHs) from coordinators' perspectives.
J Am Board Fam Med 2016 Jan-Feb;29(1):90-101. doi: 10.3122/jabfm.2016.01.150175.
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Keywords: Care Coordination, Patient-Centered Healthcare, Healthcare Delivery