Transitions in Care

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.

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

This research aims to design and develop novel wearable technologies that can improve care coordination during prehospital encounters and, ultimately, improve patient outcomes and achieve patient-centered care delivery and coordination.

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 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.

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.