Project ACHIEVE: Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence

OBJECTIVES Project ACHIEVE’s long term objective will be to provide detailed, comprehensive guidance for the design, implementation and maintenance of transitional care strategies for hospital-to-postacute care that optimize patient and caregiver outcomes in varying healthcare contexts. Specific Aims 1) Identify what transitional care outcomes matter most to patients and caregivers, and which combinations and forms of transitional care services could provide the best patient and caregiver outcomes among diverse patient and caregiver populations at varying risk for poor outcomes in diverse settings. a. Clinical outcomes include 30-day readmissions, emergency department visits, adverse drug events b. Patient outcomes include patient experience and engagement, anxiety, support, social isolation, selfreported health status, and financial burden c. Caregiver outcomes include caregiver experience, anxiety, burden, social support 2) Develop, pilot test, validate and collect data on surveys and other evaluation measures of above outcomes. 3) Evaluate the effectiveness of clusters of transitional care services and determine which are most effective in a sample of existing care transitions communities in CCTPs, QIOs, and HENs by surveying patients, caregivers, and providers, and by comparing patient-centered outcomes in different subpopulation-contexts. 4) Identify barriers and facilitators to the scalability of different combinations and forms of transitional care services for different types of care settings and communities. 5) Disseminate research findings to patients, caregivers and providers on the best evidence regarding how to achieve optimal transitional care services and outcomes.