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2. Patient-Centered Approaches to Transitional Care Research and Implementation

Author

Parry, Carly, Johnston-Fleece, Michelle, Johnson, Maurice C., Shifreen, Aaron, and Clauser, Steven B.

Subjects
Introduction, transitional care, comparative effectiveness research, patient-centered
Abstract

Background: This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI’s approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process. Objectives: This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care. It provides an overview of the state of the care transitions field, a description of PCORI’s programmatic objectives, highlights of the patient and stakeholder engagement activities that have taken place during the course of these studies, and a brief overview of PCORI’s Transitional Care Evidence to Action Network, a learning community designed to foster collaboration between investigators and their research teams and enhance the collective impact of this body of work. Conclusions: The papers in this Special Issue articulate challenges, lessons learned, and new directions for measurement, stakeholder engagement, implementation, and methodological and design approaches that reflect the complexity of transitional care comparative effectiveness research and seek to move the field toward a more holistic understanding of transitional care that integrates social needs and lifespan development into our approaches to improving care transitions.

Published
2021

5. Aging: Adding complexity, requiring skills.

Author

Cassel, Christine K., Johnston-Fleece, Michelle, and Reddy, Siddharta

Subjects
*MEDICAL care for older people, *CHRONIC diseases, *MEDICAL care, *SICK people, *TERMINAL care, *AGING
Abstract

The role of systems in addressing the needs of elderly and chronically ill populations remains a far from universal way of thinking, much less practice, in health care. Re-engineering the current fragmented system to align providers, patients and payment models to facilitate proactive management of conditions associated with advanced age and/or one or more chronic diseases – rather than responding to costly consequences of a health care system optimized for acute care conditions – will be a major challenge for all stakeholders. There are, however, promising success stories that are taking place in the United States today that may provide a model for improvement. The authors define the issues faced by the health care providers and payers that arise when providing care for the elderly and those with chronic conditions – issues that threaten to overwhelm the financial and human health care resources that exist to serve these populations. They define innovative ways of thinking about systems of care, and provide examples of unique systems that have applied theory into practice. These successful leaders may offer lessons in proactively managing complex health conditions, overcoming communication barriers and using technology to complement the necessary human touch that is essential to health care delivery. [ABSTRACT FROM AUTHOR]

Published
2010
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6. Aging: Adding complexity, requiring skills.

Author

Rouse, W.B., Cortese, D.A., Cassel, Christine K., Johnston-Fleece, Michelle, and Reddy, Siddharta

Abstract

The role of systems in addressing the needs of elderly and chronically ill populations remains a far from universal way of thinking, much less practice, in health care. Re-engineering the current fragmented system to align providers, patients and payment models to facilitate proactive management of conditions associated with advanced age and/or one or more chronic diseases – rather than responding to costly consequences of a health care system optimized for acute care conditions – will be a major challenge for all stakeholders. There are, however, promising success stories that are taking place in the United States today that may provide a model for improvement. The authors define the issues faced by the health care providers and payers that arise when providing care for the elderly and those with chronic conditions – issues that threaten to overwhelm the financial and human health care resources that exist to serve these populations. They define innovative ways of thinking about systems of care, and provide examples of unique systems that have applied theory into practice. These successful leaders may offer lessons in proactively managing complex health conditions, overcoming communication barriers and using technology to complement the necessary human touch that is essential to health care delivery. [ABSTRACT FROM AUTHOR]

Published
2010

7. Aging: adding complexity, requiring skills.

Author

Cassel CK, Johnston-Fleece M, and Reddy S

Subjects
Adolescent, Adult, Aged, Child, Child, Preschool, Chronic Disease therapy, Geriatric Nursing, Humans, Infant, Infant, Newborn, Middle Aged, Models, Theoretical, Systems Integration, United States, Young Adult, Aging, Health Expenditures trends
Abstract

The role of systems in addressing the needs of elderly and chronically ill populations remains a far from universal way of thinking, much less practice, in health care. Re-engineering the current fragmented system to align providers, patients and payment models to facilitate proactive management of conditions associated with advanced age and/or one or more chronic diseases - rather than responding to costly consequences of a health care system optimized for acute care conditions - will be a major challenge for all stakeholders. There are, however, promising success stories that are taking place in the United States today that may provide a model for improvement. The authors define the issues faced by the health care providers and payers that arise when providing care for the elderly and those with chronic conditions - issues that threaten to overwhelm the financial and human health care resources that exist to serve these populations. They define innovative ways of thinking about systems of care, and provide examples of unique systems that have applied theory into practice. These successful leaders may offer lessons in proactively managing complex health conditions, overcoming communication barriers and using technology to complement the necessary human touch that is essential to health care delivery.

Published
2010

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