UK approved to lead $14.9 million national research project to study patient-care transitions

By Kristi Lopez – University of Kentucky

LEXINGTON, Ky. (Oct. 8, 2014) – The University of Kentucky has been approved to lead a $14.9 million national research project to identify the most effective approaches for patient-care transitions as they move between hospitals, nursing homes and their own homes.

UK was selected to lead the project by the Patient-Centered Outcomes Research Institute (PCORI), an independent, non-profit organization authorized by Congress as part of the Patient Protection and Affordable Care Act. Dr. Mark V. Williams, director of UK’s Center for Health Services Research, has been tapped to lead a three-year contract for one of PCORI’s priority projects, “Effectiveness in Transitional Care.”

The study, Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence), combines the expertise of patients, caregivers and stakeholders with national leaders in care-transition research. The collaborative team includes experts in statistics, surveys, implementation science and quality improvement from 14 organizations, including UK, University of Pennsylvania, Boston Medical Center, Telligen, Westat and Kaiser Permanente.

The study will identify which combination of transitional care services improve outcomes that matter most to patients and their caregivers as they leave the hospital and return to their homes. Patient characteristics, care settings and other factors will be incorporated in the analysis to determine which transitional care services work best for whom and under what circumstances.

Poorly managed patient care transitions between hospitals, clinics, home or nursing homes can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and ER visits, said Williams, who is also professor of internal medicine and health policy and management at UK.

Patients in the U.S. suffer harm too often as they move between sites of healthcare, and their caregivers experience significant burden, Williams noted. Unfortunately, the usual approach to healthcare does not support continuity and coordination during such “care transitions” between hospitals, clinics, home or nursing homes.

The goal is for Project ACHIEVE to determine which transitional care services most effectively produce patient and caregiver desired outcomes among diverse patient and caregiver populations in different healthcare settings, Williams said.

Using the results, the project team will develop concrete, actionable recommendations regarding how best to implement strategies and provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them.

“Receiving this contract from PCORI to lead this project is a testament to the outstanding work being done by a very capable and expert team at the University of Kentucky,” said Dr. Michael Karpf, UK executive vice president for health affairs.  “Care transitions can be a challenge for patients, their families and providers and this project will give evidence-based information on how we can make significant improvements and impact in this area.”