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

ABSTRACT:

Background

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.

Methods/design

Project ACHIEVE focuses on diverse Medicare populations such as indiv

SUBMITTER: Li J 

PROVIDER: S-EPMC4759940 | biostudies-literature | 2016 Feb

REPOSITORIES: biostudies-literature