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AHRQ-Funded Projects
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Implementing Personalized Cross-Sector Transitional Care Management to Promote Care Continuity, Reduce Low-Value Utilization, and Reduce the Burden of Treatment for High-Need, High-Cost Patients
This research will integrate cross-sector care alerts and interoperable personalized care planning into the existing Coordinating Transitions Intervention (CTI) tool and evaluate the impact of the revised tool on patient burden, care team collaboration, and utilization value for high-need, high-cost patients.
Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities
This research aims to determine the effectiveness of a program designed to reduce medication-related issues among patients during the hospital-to-skilled nursing facility transition.
Health Information Exchange Utilization and Inter-Hospital Transfer Outcomes
This research’s goal is to show that interoperability, including adoption of regional health information exchanges, improves mortality rates and care efficiency at the population and patient levels.
Using Social Knowledge Networking (SKN) Technology To Enable Meaningful Use of EHR Technology
This pilot project implemented a Social Knowledge Networking system and concluded that it supported progress toward meaningful use of medication reconciliation technology in an electronic health record.
Using Location-Based Smartphone Alerts Within a System of Care Coordination
The research team developed a smartphone application that notifies primary care providers when patients receive care in the hospital or emergency department, allowing for rapid followup care.
Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization
This research demonstrated primary care providers’ complementary use of “push” and “pull” health information exchange technologies to meet their information needs and provides evidence that “pull” exchange reduces potentially avoidable healthcare utilization.
Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions
Researchers refined and implemented integrated digital healthcare enhancements to a previously developed, interactive, patient-centered discharge toolkit, finding that while patients used the toolkit, there were no significant changes in post-discharge healthcare utilization.
Electronic Medication Adherence Reporting and Feedback During Care Transitions
This research assessed the utilization of a “smart” pillbox, a prefilled electronic medication tray that sends electronic alerts and reports to patients, caregivers, and primary care providers for patients discharged from the hospital, finding an increased medication adherence among patients on five or more chronic medications.
Developing an Interactive Patient-Centered mHealth Tool to Enhance Post-Cystectomy Care
This project explored novel strategies that incorporated patient-centered outcomes and improved post-discharge care for radical cystectomy as well as other surgical oncology procedures that have the potential to reduce post-surgical readmissions.
Information Needs of Homecare Nurses During Admission and Care Planning
This study analyzed and modeled information requirements, decision making, and workflow of homecare nurses admitting patients leading to the development, review, and dissemination of information technology design and implementation recommendations in this setting.
