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.

Public Health Relevance

Patients are vulnerable to adverse events, including medication errors and hospital readmissions following hospital discharge; many of these adverse events are attributable to fragmented communication between clinicians in different settings. Because patients referred for skilled home health care (HHC) services (e.g., nursing, therapy) after hospital discharge are older and more debilitated than patients discharged home without HHC services, adverse events such as hospital readmissions can be devastating, and often contribute to progressive functional disability and even death. To address suboptimal coordination of care between hospital clinicians and HHC nurses, we propose three aims in this career development award that will (1) promote understanding of barriers and facilitators to care coordination with HHC nurses, (2) define which HHC patients are at risk of hospital readmission, and (3) develop and pilot test an innovative handoff intervention to connect hospitalists and HHC nurses with the goal of reducing adverse events including medication errors and hospital readmissions.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Clinical Investigator Award (CIA) (K08)
Project #
1K08HS024569-01A1
Application #
9243880
Study Section
HSR Health Care Research Training SS (HCRT)
Program Officer
Willis, Tamara
Project Start
2016-09-30
Project End
2021-09-29
Budget Start
2016-09-30
Budget End
2017-09-29
Support Year
1
Fiscal Year
2016
Total Cost
Indirect Cost
Name
University of Colorado Denver
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
041096314
City
Aurora
State
CO
Country
United States
Zip Code
80045
Burke, Robert E; Jones, Christine D; Hosokawa, Patrick et al. (2018) Influence of Nonindex Hospital Readmission on Length of Stay and Mortality. Med Care 56:85-90
Sterling, Madeline R; Shaw, Amy L; Leung, Peggy Bk et al. (2018) Home care workers in heart failure: a systematic review. J Multidiscip Healthc 11:481-492
Jones, Christine D; Burke, Robert E (2018) Web Exclusive. Annals for Hospitalists Inpatient Notes - Getting Past the ""Black Box""-Opportunities for Hospitalists to Improve Postacute Care Transitions. Ann Intern Med 168:HO2-HO3
Breathett, Khadijah; Jones, Jacqueline; Lum, Hillary D et al. (2018) Factors Related to Physician Clinical Decision-Making for African-American and Hispanic Patients: a Qualitative Meta-Synthesis. J Racial Ethn Health Disparities 5:1215-1229
Jones, Christine D; Bowles, Kathryn H; Richard, Angela et al. (2017) High-Value Home Health Care for Patients With Heart Failure: An Opportunity to Optimize Transitions From Hospital to Home. Circ Cardiovasc Qual Outcomes 10:
Jones, Christine D; Jones, Jacqueline; Richard, Angela et al. (2017) ""Connecting the Dots"": A Qualitative Study of Home Health Nurse Perspectives on Coordinating Care for Recently Discharged Patients. J Gen Intern Med 32:1114-1121