Individuals with Chronic Care Needs

Evaluating treatment burden in patients with complex needs receiving a transition of care intervention: A rapid qualitative analysis.

Citation
Bowen E, Ali N, Anderson AJ, Krolikowski A, Hewner S. Evaluating treatment burden in patients with complex needs receiving a transition of care intervention: A rapid qualitative analysis. Clin Nurs Res. 2025 Sep 28:10547738251378678. doi: 10.1177/10547738251378678. Epub ahead of print. PMID: 41015909.
Principal Investigator
Hewner, Sharon
Project Name
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

Factors associated with perceived medication safety during transitions of care in patients with cancer: A secondary data analysis of a cross-sectional survey.

Citation
Cho Y, Hwang M, Gong Y, Jiang Y. Factors associated with perceived medication safety during transitions of care in patients with cancer: A secondary data analysis of a cross-sectional survey. Eur J Oncol Nurs. 2025 Jun;76:102857. doi: 10.1016/j.ejon.2025.102857. Epub 2025 Mar 4. PMID: 40068277; PMCID: PMC12146089.
Principal Investigator
Jiang, Yun
Gong, Yang
Project Name
Patient Engagement in Reporting Medication Events During Transitions of Care

Real-time symptom monitoring using electronic patient-reported outcomes: A prospective study protocol to improve safety during care transitions for patients with multiple chronic conditions.

Citation
Plombon S, Rudin RS, Rodriguez J, Garabedian P, Lipsitz S, Edelen M, Leeson M, Smith M, Konieczny K, Dalal AK. Real-time symptom monitoring using electronic patient-reported outcomes: A prospective study protocol to improve safety during care transitions for patients with multiple chronic conditions. J Hosp Med. 2025 May;20(5):534-543. doi: 10.1002/jhm.70013. Epub 2025 Feb 16. PMID: 39956797.
Principal Investigator
Dalal, Anuj K.
Project Name
Real-Time Symptom Monitoring Using ePROs to Prevent Adverse Events During Care Transitions

The impact of an adaptive mHealth intervention on improving patient-provider health care communication: Secondary analysis of the DIAMANTE trial.

Citation
Leng L, Arévalo Avalos MR, Aguilera A, Lyles CR. The impact of an adaptive mHealth intervention on improving patient-provider health care communication: Secondary analysis of the DIAMANTE trial. JMIR Mhealth Uhealth. 2025 Jul 17;13:e64296. doi: 10.2196/64296. PMID: 40674692; PMCID: PMC12289220.
Principal Investigator
Aguilera, Adrian
Project Name
Improving Diabetes and Depression Self-Management Via Adaptive Mobile Messaging

Developing and evaluating SEE-Diabetes: A patient-centered educational decision Support System for Diabetes care.

Citation
Narindrarangkura P, Dejhansathit S, Khan U, Day M, Boren SA, Simoes EJ, Kim MS. Developing and evaluating SEE-Diabetes: A patient-centered educational decision Support System for Diabetes care. J Eval Clin Pract. 2025 Feb;31(1):e14234. doi: 10.1111/jep.14234. Epub 2024 Nov 4. PMID: 39494699; PMCID: PMC12145152.
Principal Investigator
Kim, Min Soon
Project Name
Patient-Centered Diabetes Education as an Integral Part of an Electronic Clinic Note using the SEE-Diabetes Modules

Harnessing health information technology to promote equitable care for patients with limited English proficiency and complex care needs.

Citation
Strechen I, Wilson P, Eltalhi T, Piche K, Tschida-Reuter D, Howard D, Sutor B, Tiong I, Herasevich S, Pickering B, Barwise A. Harnessing health information technology to promote equitable care for patients with limited English proficiency and complex care needs. Trials. 2024 Jul 4;25(1):450. doi: 10.1186/s13063-024-08254-y. PMID: 38961501; PMCID: PMC11223355.
Principal Investigator
Barwise, Amelia K.
Project Name
Harnessing Health Information Technology to Promote Equitable Care for Patients with Limited English Proficiency and Complex Care Needs

The social, mental, and physical health impacts of the COVID-19 pandemic on people with HIV: Protocol of an observational international multisite study.

Citation
Cuca YP, Horvat Davey C, Corless IB, Phillips JC, Sierra-Perez ÁJ, Solís Báez S, Iwu E, Sabone M, Mulaudzi MT, Murphey C, Shaibu S, Chen WT, Santa Maria D, Schnall R, Palmieri P, Apiruknapanond P, Wang T, de Jesús T, Huang E, Broussard J, Dawson-Rose C. The social, mental, and physical health impacts of the COVID-19 pandemic on people with HIV: Protocol of an observational international multisite study. J Assoc Nurses AIDS Care. 2024 Jan-Feb 01;35(1):60-74. doi: 10.1097/JNC.0000000000000444. Epub 2023 Dec 14. PMID: 38096186; PMCID: PMC10749681.
Principal Investigator
Schnall, Rebecca
Project Name
Dissemination of the WiseApp for Improving Health Outcomes Across Settings

Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) in adults - A randomised controlled trial.

Citation
Dorr DA, Montgomery E, Ghumman AJ, Michaels L, Rolbiecki A, Canfield S, Shaffer V, Johnson B, Lockwood M, Ghosh P, Martinez W, Koopman R; COACH Consortium. Study protocol: Collaboration Oriented Approach to Controlling High Blood Pressure (COACH) in adults - A randomised controlled trial. BMJ Open. 2024 Jul 8;14(7):e085898. doi: 10.1136/bmjopen-2024-085898. PMID: 38977368; PMCID: PMC11256044.
Principal Investigator
Dorr, David
Koopman, Richelle J.
Project Name
Collaboration-Oriented Approach to Controlling High Blood Pressure (COACH)

Assessing the seasonality of lab tests among patients with Alzheimer's disease and related dementias in OneFlorida Data Trust.

Citation
Han W, Bhasuran B, Muse VP, Brunak S, Lin L, Hanna K, Huang Y, Bian J, He Z.Assessing the seasonality of lab tests among patients with Alzheimer's disease and related dementias in OneFlorida Data Trust. AMIA Annu Symp Proc. 2025 May 22;2024:483-492. PMID: 40417579; PMCID: PMC12099435.
Principal Investigator
He, Zhe
Lustria, Mia Liza A.
Project Name
LabGenie: A Patient-Engagement Tool to Aid Older Adults' Understanding of Lab Test Results

Patient Intestinal Failure-ECHO Project (PIF-ECHO)

Description

This study will evaluate the feasibility and effectiveness of providing chronic intestinal failure patients and their family caregivers with direct access to live, virtual, multi-disciplinary (multi-D) support and education on best practices from a team of experts and peers. Such support can improve patient outcomes by enhancing knowledge, increasing confidence in self-care, and fostering a support network where patients can share lived experiences.

Grant Number
R03 HS030321
Principal Investigator(s)
Iyer, Kishore R.