Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness

BMC Health Services Research
Jing LiProject ACHIEVE Team

Abstract

Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors' offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated. Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate t...Continue Reading

References

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Citations

Nov 14, 2016·Journal of Primary Care & Community Health·Niharika KhannaDavid Sharp
Apr 4, 2017·Journal of the American Geriatrics Society·Mary D NaylorMark V Williams
Oct 17, 2017·Journal of Nursing Care Quality·Dorothy HungFrancesca Nicosia
Aug 23, 2020·The Journal of Nursing Administration·Kristi L CrossClayton J Shuman
Aug 24, 2019·International Journal of Nursing Studies·Hooman ShahsavariJafar Aliheydari Mamaghani
Jun 7, 2021·Heart & Lung : the Journal of Critical Care·Sijia WeiBradi Granger
Jun 12, 2021·Patient Preference and Adherence·Jessica Miller ClouserJing Li

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Software Mentioned

AIM
ACHIEVE
UCINET
RE

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