Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

Summary

Funded by the Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.

Conditions

• Care Transitions

Interventions

BEHAVIORAL

Patient Communication and Care Management

Received the following Transitional Care strategies: 1. Helpful Health Care Contact OR Symptom Management 2. Post-discharge Care Consultation 3. Patient Goal/Preference Assessment 4. Plain Language Communication in Hospital 5. Plain Language Communication at Home 6. Transition Summary for Patients and Family Caregivers

BEHAVIORAL

Home-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies: 1. Transition Team 2. Home visits 3. Plain Language Communication at Home 4. Promote Trust at Home 5. Referral to Community Services 6. Follow-up Appointment

BEHAVIORAL

Hospital-Based Trust, Plain Language, and Coordination

Received the following Transitional Care Strategies: 1. Post-discharge care consultation 2. Identify High-Risk Patients and Intervene 3. Medication Reconciliation 4. Plain Language Communication in Hospital 5. Promote Trust in the Hospital 6. Transition Summary for Patients and Family Caregivers

BEHAVIORAL

Patient/Caregiver Assessment and Provider Information Exchange

Received the following Transitional Care Strategies: 1. Patient Goal/Preference Assessment 2. Identify High-Risk Patients and Intervene 3. Timely Exchange of Critical Patient Information among Providers 4. Patient/Family Caregiver Transitional Care Needs Assessment

BEHAVIORAL

Assessment and Teach Back

Received the following Transitional Care Strategies: 1. Post-discharge care consultation 2. Language Assessment 3. Teach Back for Information and Skills

OTHER

Standard of Care (Reference)

No specific Transitional Care Strategy

Sponsors & Collaborators

• University of Pennsylvania

  collaborator OTHER

• Boston Medical Center

  collaborator OTHER

• Westat

  collaborator OTHER

• Kaiser Permanente

  collaborator OTHER

• Telligen, Inc.

  collaborator INDUSTRY

• University of Illinois at Chicago

  collaborator OTHER

• Hospital Research & Education Trust, American Hospital Association

  collaborator UNKNOWN

• Joint Commission Resources

  collaborator UNKNOWN

• America's Essential Hospitals

  collaborator OTHER

• Louisiana State University Health Sciences Center Shreveport

  collaborator OTHER

• United Hospital Fund

  collaborator OTHER

• Caregiver Action Network

  collaborator UNKNOWN

• National Association of Area Agencies on Aging

  collaborator UNKNOWN

• Mark Williams

  lead OTHER

Principal Investigators

• Mark V Williams, MD · University of Kentucky

Eligibility

Min Age

18 Years

Sex

ALL

Healthy Volunteers

No

Timeline & Regulatory

Start

2015-03-31

Primary Completion

2019-04-30

Completion

2019-06-30

Countries

• United States

Study Locations