Hewner, Sharon

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.

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Project Dates: 
April 1, 2021 to March 31, 2026

Reducing emergency room visits and in-hospitalizations by implementing best practice for transitional care using innovative technology and big data.

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Integrating social determinants of health into primary care clinical and informational workflow during care transitions.

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Comparative effectiveness of risk-stratified care management in reducing readmissions in Medicaid adults with chronic disease.

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Frequent emergency department utilization and behavioral health diagnoses.

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Aligning population-based care management with chronic disease complexity.

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Informatics’ role in integrating population and patient-level knowledge to improve care transitions in complex chronic disease.

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Integrating social context into comprehensive shared care plans: A scoping review.

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The roles of chronic disease complexity, health system integration, and care management in post-discharge healthcare utilization in a low-income population.

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Coordinating Transitions: Health Information Technology Role in Improving Multiple Chronic Disease Outcomes - Final Report

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