Transitions in Care

Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities

Description: 

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.

Principal Investigator: 
Project Dates: 
September 30, 2020 to July 31, 2025

Health Information Exchange Utilization and Inter-Hospital Transfer Outcomes

Description: 
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.
Principal Investigator: 
Project Dates: 
April 1, 2019 to January 31, 2023

Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization

Description: 

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.

Principal Investigator: 
Project Dates: 
September 30, 2016 to September 29, 2019

Using Location-Based Smartphone Alerts Within a System of Care Coordination

Description: 

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.

Principal Investigator: 
Project Dates: 
September 30, 2016 to September 29, 2019

Using Social Knowledge Networking (SKN) Technology To Enable Meaningful Use of EHR Technology

Description: 

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.

Principal Investigator: 
Project Dates: 
September 30, 2016 to September 28, 2018

Interactive Patient-Centered Discharge Toolkit To Promote Self-Management During Transitions

Description: 

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.

Principal Investigator: 
Project Dates: 
September 1, 2016 to August 31, 2019

Electronic Medication Adherence Reporting and Feedback During Care Transitions

Description: 

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.

Principal Investigator: 
Project Dates: 
May 1, 2016 to April 30, 2019

Information Needs of Homecare Nurses During Admission and Care Planning

Description: 

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.

Principal Investigator: 
Project Dates: 
April 1, 2016 to March 31, 2020

Developing an Interactive Patient-Centered mHealth Tool to Enhance Post-Cystectomy Care

Description: 

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.

Principal Investigator: 
Project Dates: 
April 1, 2016 to March 31, 2019

Open & Act: Tracking Health Care Team Response to EHR Asynchronous Alerts

Description: 

This project analyzed secondary data to identify factors associated with timely opening of electronic health record-based asynchronous alerts, timely response to the alerts, and patient outcomes.

Principal Investigator: 
Project Dates: 
September 30, 2014 to September 29, 2017