As chronic illnesses progress over time, patients experience clinical status changes that require care transitions across health care settings or to new phases of care. All transitions present opportunities for high quality patient-centered care; however, in practice many care transitions are poorly managed and many decisions do not respect patient values or take available evidence into account. This application proposes to develop a center for patient-centered outcomes research (PCOR) at the University of Missouri (MU) with a thematic focus on improving patient care transitions across health care settings or from one phase of care to another. To build long-term sustainability for conducting patient-centered outcomes research the MU Center will: (1) develop MU's capabilities in PCOR by mentoring investigators, supporting pilot studies, providing research training, and new hiring; (2) foster development of skills and capabilities to work with large data sets using advanced analytic methods to study comparative treatment effectiveness; (3) build research expertise on practice-changing interventions to support care transitions; and (4) engage stakeholders through focus groups, a patient advisory panel, and a novel social networking and tailored messaging platform that facilitates information gathering, feedback from participants to investigators, and dissemination. The MU Center will also develop digital infrastructure to support data collection and analysis, test novel research designs, and facilitate building a regional vascular surgery registry. The three associated projects will include patients with ischemic limbs undergoing an inpatient procedure, patients transitioning from skilled nursing facilities to the community, and patients receiving or being considered for opioid therapy for chronic pain in primary care practices in the American Academy of Family Physicians National Research Network. They will enhance the Center's expertise in using large data sets and developing strategies for practice change while engaging stakeholders both to improve the research and to facilitate its dissemination and implementation. The MU Center will be supported by strong internal and external advisors, and the application proposes a robust evaluation process.
The proposed MU Center for PCOR will develop capabilities to conduct research and disseminate results related to transitions patients experience from one site of care to another, such as hospital to home, or from one phase of care to another, such as receiving surgery. Such research is needed to improve many aspects of chronic illnesses care, which is increasingly the main focus of much contemporary medical care.
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