Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care

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Project Summary/Abstract This is a revised submission for an AHRQ Mentored Clinical Scientist Research Career Development Award (K08) by Christine D. Jones, MD, MS. My overall career goal is to develop and implement interventions that improve patient outcomes through more effective care coordination between clinicians. Care transitions from hospital to home can be perilous for patients, and fragmented communication contributes to many preventable adverse events during this transition. Home health care (HHC) is increasingly employed with the intent to improve care transitions, but even with home support, older adults remain vulnerable to adverse events after discharge, including hospital readmissions, which contribute to progressive disability for these patients. With this career development award, I will develop an intervention that improves care coordination between hospitalists and HHC nurses that aims to reduce adverse patient outcomes, including medication errors and hospital readmissions. Candidate and Mentors: I am an Assistant Professor of Medicine at the University of Colorado where I practice as an adult medicine hospitalist. I completed a research fellowship and have conducted studies to describe barriers to care coordination, a systematic review of interventions to reduce readmissions, and analyses of HHC referrals at hospital discharge. I have built productive relationships with my mentors and have completed two manuscripts – one published, one in press - with my primary mentor, Dr. Frederick Masoudi. Research and Training: I will build on my prior research through three complementary research and training aims that will inform an intervention to improve the quality of care coordination between hospitalists and HHC nurses caring for older adults after acute hospitalization. I will: (1) employ qualitative methods to understand HHC nurse, patient, and caregiver experiences of care coordination, (2) generate predictive models to identify modifiable risk factors for 30-day readmissions from HHC within national Medicare data, and (3) develop, implement, and evaluate a pilot intervention to connect hospitalists and HHC nurses to optimize post-discharge care coordination and reduce adverse patient outcomes. At award completion, I will have the training and skills to be a successful independent investigator and will pursue funding for a pragmatic clinical trial to test the effectiveness of an intervention to improve care coordination between hospitalists and HHC nurses. Summary: Effective care coordination between hospitalists and HHC nurses is critical to support high-quality care transitions for vulnerable patients after acute hospitalization. The proposed research will inform an intervention to improve care coordination between hospitalists and HHC nurses and enhance outcomes for patients receiving HHC services after hospitalization. This award will support my development into an independent investigator with expertise in enhancing care coordination between clinicians to improve outcomes for the growing number of patients discharged with HHC services.