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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)
Hewner, Sharon

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

Citation
Vest J. Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Health Care Utilization - Final Report. (Prepared by Indiana University-Purdue University at Indianapolis under Grant No. R01 HS024556). Rockville, MD: Agency for Healthcare Research and Quality, 2019.
Principal Investigator
Vest, Joshua Ryan
Project Name
Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization

The associations between query-based and directed health information exchange with potentially avoidable use of health care services.

Citation
Vest JR, Unruh MA, Shapiro JS, Casalino LP. The associations between query-based and directed health information exchange with potentially avoidable use of health care services. Health Serv Res. 2019 May 21. doi:
10.1111/1475-6773.13169. [Epub ahead of print]. PMID: 31112303.
Principal Investigator
Vest, Joshua Ryan
Project Name
Use of Push and Pull Health Information Exchange Technologies by Ambulatory Care Practices and the Impact on Potentially Avoidable Healthcare Utilization

Disparities in patient-reported interest in web-based patient portals: survey at an urban academic safety-net hospital.

Citation
Sadasivaiah S, Lyles CR, Kiyoi S, Wong P, Ratanawongsa N. Disparities in patient-reported interest in web-based patient portals: survey at an urban academic safety-net hospital. J Med Internet Res. 2019 Mar 26;21(3):e11421. doi: 10.2196/11421. PMID: 30912747.
Principal Investigator
Lyles, Courtney
Project Name
Engaging Diverse Patients in Using an Online Patient Portal

Effect of hospital readmission reduction on patients at low, medium, and high risk of readmission in the Medicare population.

Citation
Blecker S, Herrin J, Kwon JY, Grady JN, Jones S, Horwitz LI. Effect of hospital readmission reduction on patients at low, medium, and high risk of readmission in the Medicare population. J Hosp Med. 2018 Aug 1;13(8):537-543.
doi: 10.12788/jhm.2936. Epub 2018 Feb 12. PMID: 29455229.
Principal Investigator
Blecker, Saul B.
Project Name
Health Information Technology in Heart Failure Care

First opioid prescription and subsequent high-risk opioid use: a national study of privately insured and Medicare Advantage adults.

Citation
Zhang Y, Johnson P, Jeng PJ, et al. First opioid prescription and subsequent high-risk opioid use: a national study of privately insured and Medicare Advantage adults. J Gen Intern Med 2018 Sep 11. doi: 10.1007/s11606-018-4628-y. [Epub ahead of print]. PMID: 30206790.
Principal Investigator
Ancker, Jessica
Project Name
Improving Healthcare Quality with User-Centric Patient Portals