Transitions in Care

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)

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.

Grant Number
R01 HS024556
Principal Investigator(s)

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.

Grant Number
R21 HS024587
Principal Investigator(s)