Defragmenting Care for Patients at Increased Risk of Hospitalization: A Conference on Comprehensive Care

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Project Summary/Abstract This application requests support for a novel 1-year dissemination and implementationconference grant in which the University of Chicago Comprehensive Care Program (CCP) research team will engage ~50 healthcare leaders and clinicians and social service providers in a hybrid in-person/virtual 1-day conference in Chicago and monthly virtual sessions for the duration of the project period. The conference will focus on sharing dissemination tools and implementation frameworks for evidence-based care delivery models that increase relational continuity across inpatient and outpatient settings for patients at increased risk of hospitalization and explicitly address both complex medical and social needs. This focus is motivated by evidence that greater continuity of care can improve outcomes for patients at increased risk of hospitalization. This evidence includes studies of our Comprehensive Care Program (CCP) that find that providing patients at increased risk of hospitalization access to care from the same doctor in and out of the hospital can reduce hospitalization and improve health outcomes. As a result of these positive findings, interest in implementing similar comprehensive care models has grown, with several community and academic medical centers across the U.S. and internationally adapting CCP in their settings with our guidance. This proposal builds on several years of successfully facilitating relevant learning collaboratives that have engaged a diverse set of healthcare providers and health system types through virtual meetings in the context of COVID-19, including a recent Comprehensive Care Grand Rounds virtual meeting series. Participants in those meetings have expressed significant interest in building a community around “comprehensive care” with in-an person convening opportunity to share implementation best practices and evaluation methods. We propose 3 specific aims for this conference grant: Aim 1: To hold a conference in Fall 2023 that convenes stakeholders who have implemented or are interested in implementing models of care that defragment care for patients at increased risk of hospitalization. Aim 2: Through conference presentations and interactive workshops, to share tools and frameworks for how to successfully implement and evaluate comprehensive care models in a range of health care settings to support the dissemination of evidence-based comprehensive care models and the development of research to evaluate these models at other sites. Aim 3: To create and share deliverables for participants to continue to participate in dialogue and knowledge sharing throughout the course of the year following the conference, including through a web-based forum to facilitate relationship-building amongst participates and to house recordings fromthe conference workshops and presentation and implementation and evaluation resources.