Transitions in Care


EnhanCed HandOffs (ECHO)

Description

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.

Grant Number
R01 HS029324
Principal Investigator(s)

Use of Electronic Health Record Metadata to Assess Hospital Discharge Planning for Post-Acute Transitions

Description

This research will develop and test novel approaches for using electronic health record metadata to characterize and evaluate hospital discharge planning practices, with the long-term goal of providing tools to monitor and strengthen specific behaviors within discharge workflows that optimize post-acute transitions of care.

Grant Number
R21 HS028865
Principal Investigator(s)

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

Description

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.

Grant Number
R01 HS028000
Principal Investigator(s)