title: Project ACHIEVE - using implementation research to guide the evaluation of transitional care effectiveness.
abstract: BACKGROUND
  Poorly managed hospital discharges and care transitions between health care facilities can cause poor outcomes for both patients and their caregivers. Unfortunately, the usual approach to health care delivery does not support continuity and coordination across the settings of hospital, doctors' offices, home or nursing homes. Though complex efforts with multiple components can improve patient outcomes and reduce 30-day readmissions, research has not identified which components are necessary. Also we do not know how delivery of core components may need to be adjusted based on patient, caregiver, setting or characteristics of the community, or how system redesign can be accelerated.
  
  
  METHODS
  Project ACHIEVE focuses on diverse Medicare populations such as individuals with multiple chronic diseases, patients with low health literacy/numeracy and limited English proficiency, racial and ethnic minority groups, low-income groups, residents of rural areas, and individuals with disabilities. During the first phase, we will use focus groups to identify the transitional care outcomes and components that matter most to patients and caregivers to inform development and validation of assessment instruments. During the second phase, we will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. Using a mixed-methods approach for this evaluation, we will study historical (retrospective) and current and future (prospective) groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data. In this natural experiment observational study, we use a fractional factorial study design to specify comparators and estimate the individual and combined effects of key transitional care components.
  
  
  CONCLUSIONS
  Our study will determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings. Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. Finally, this work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities.
  
  
  BACKGROUND
  Registered as NCT02354482 on clinicaltrials.gov on 1/29/2015.
authors.affiliation: Administrative Director of the Center for Health Services Research, Assistant Professor of Internal Medicine, University of Kentucky, Lexington, KY, USA. Jingli.tj@uky.edu.
authors.forename: Jing
authors.initials: J
authors.lastname: Li
authors.affiliation: Care Transitions Theme Support Center, Telligen, Englewood, CO, USA. JBrock@telligen.com.
authors.forename: Jane
authors.initials: J
authors.lastname: Brock
authors.affiliation: Family Medicine, Boston University School of Medicine, Boston, MA, USA. Brian.Jack@bmc.org.
authors.forename: Brian
authors.initials: B
authors.lastname: Jack
authors.affiliation: Research Scientist, Research and Evaluation, Kaiser Permanente, Pasadena, CA, USA. Brian.Mittman@va.gov.|US Department of Veterans Affairs Greater Los Angeles Healthcare System, VA Center for Implementation Practice and Research, Los Angeles, CA, USA. Brian.Mittman@va.gov.|UCLA School of Medicine, UCLA Clinical Translational Science Institute, Los Angeles, CA, USA. Brian.Mittman@va.gov.
authors.forename: Brian
authors.initials: B
authors.lastname: Mittman
authors.affiliation: Director of NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA. naylor@nursing.upenn.edu.
authors.forename: Mary
authors.initials: M
authors.lastname: Naylor
authors.affiliation: Westat, Washington, D.C., USA. JoannSorra@westat.com.
authors.forename: Joanna
authors.initials: J
authors.lastname: Sorra
authors.affiliation: National Coordinating Center for Public Health Services & Systems Research, University of Kentucky, Lexington, KY, USA. glen.mays@uky.edu.
authors.forename: Glen
authors.initials: G
authors.lastname: Mays
authors.affiliation: Center for Health Services Research, Department of Internal Medicine, University of Kentucky, Kentucky Clinic J525, Lexington, KY, 40536-0284, USA. mark.will@uky.edu.
authors.forename: Mark V
authors.initials: MV
authors.lastname: Williams
mesh_terms: D000328:Adult; D000368:Aged; D002908:Chronic Disease / Q000628:therapy; D003695:Delivery of Health Care / Q000592:standards; D005006:Ethnicity / Q000706:statistics & numerical data; D017144:Focus Groups; D006801:Humans; D006278:Medicare; D008875:Middle Aged; D008913:Minority Groups; D010351:Patient Discharge; D018802:Patient-Centered Care / Q000592:standards; D011446:Prospective Studies; D044469:Racial Groups / Q000706:statistics & numerical data; D012106:Research; D012111:Residence Characteristics; D012189:Retrospective Studies; D000069341:Transitional Care / Q000592:standards*; D014481:United States