The Patient-Centered Outcomes Research Institute has awarded University of Kentucky researcher Mark Williams, M.D., a $14.9 million grant to quantify best practices for evidence-based care transitions.

Through the three-year project, researchers hope to identify which transitional care services and outcomes matter most to patients and caregivers, evaluate the comparative effectiveness of ongoing multi-component efforts at improving care transitions, and develop recommendations on best practices for the design, implementation and large-scale national spread of highly effective, patient-centered care transition programs.

The project's investigators will use qualitative and quantitative methods, including site visits, surveys, and clinical and claims data to study historical, current, and future groups of patients, caregivers, and providers. The comparators will be hospitals and communities that have implemented different clusters of transitional care interventions.

Among the cohorts studied will be diverse patient populations such as older adults, 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 special healthcare needs, including those with disabilities.

Preliminary outcomes will include patient experience, patient reported health outcomes, patient utilization of health services (30-day emergency room visits, 30-day re-hospitalizations), adverse drug events, and caregiver experience.

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