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This project developed and tested an interactive voice response supported care transition coaching intervention, e-Coach, that supports medical patients with complex conditions as they transition from hospital to home-based care.
Develops a patient Master Visit Registry (MVR), addressing the need for better information sharing among clinical organizations and enhancing their ability to give patients continuous high-quality care when they change providers. The MVR will expand upon an existing patient record-keeping system, while improving local handling and exchange of records.
Developed approaches to share data on patient clinical and diagnostic information across systems and created an implementation plan for systems integration.