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.

Grant Number
R01 HS028000
Principal Investigator(s)

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

Principal Investigator

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

Principal Investigator

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

Principal Investigator

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

Principal Investigator

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

Principal Investigator