Improving Quality of Care and Patient Outcomes During Care Transitions (R01)

This research will develop and evaluate the Perioperative Optimization of Senior Health (myPOSH) mobile application that supports care transitions and the needs of older adults undergoing surgery and their care partners.

This research will develop and evaluate a machine learning-augmented and telemedicine-augmented sociotechnical intervention for postoperative handoffs to reduce the risks of patient complications and improve patient-centered care.

This research will refine a current health information exchange platform to improve data exchange for inter-hospital transfers, evaluate its impact, and create a dissemination toolkit so that others may adopt this model.

This study will develop, evaluate, and disseminate a multicomponent intervention including a mobile health application and digital navigator training to support safe care transitions for patients with multiple chronic conditions.

This research will use digital health tools leveraging patient-reported outcomes and data from electronic health records to engage individuals with multiple chronic conditions to improve understanding of individualized risk of adverse events during care transitions.

This research will study the effectiveness of a virtual in-home program designed to reduce hospital readmissions among COPD patients post-hospitalization.

This research will examine the factors affecting cancer patients’ use of an electronic patient safety event reporting system to communicate adverse medication-related events to their care team.

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.