Patient-Centered Transitional Care

How is research on patient-centered transitional care going? A supplement on this topic funded by the Patient-Centered Outcomes Research Institute (PCORI) was recently published in Medical Care. Care transitions are “ripe with hazard,” as discussed in an editorial from Amy Berman. As pointed out by Berman, figuring out what works and what doesn’t is critical to improve health and reduce harm. Fortunately, PCORI has invested $132 million into research in this area.

This supplement describes the early results of that investment. It “focus[es] on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care,” according to Dr. Carly Parry and co-authors.

Challenges with Transitional Care Research

New evidence has not always translated into meaningful outcomes improvement. Many interventions in this area are complex, with multiple components. Comparing across interventions is difficult, as is comparing across components. Few interventions take patient desires into account. Important factors, such as quality-of-life, caregiver burden, and decision-making have historically been missing from the transitional care literature. Research featured in this supplement, however, centers on both patients and comparative effectiveness.

Highlights

A paper by Dr. Sabina Gesell and colleagues highlights the findings and implications of the PCORI transitional care portfolio so far. The authors identify three key themes:

• Delineating the function versus form of transitional care interventions. “Function” refers to the core purposes of the intervention. “Form” refers to the strategies and activities needed to carry out its function. It is critical to distinguish functions from forms. A pragmatic approach would allow for “flexible options for delivery while maintaining appropriate fidelity to the intervention.”
• Evaluating the process supporting implementation and the impact of interventions. Understanding the processes involved in program adaptations – planned and unplanned – is essential to assessing their actual effects, intended or unintended.
• Engaging stakeholders in the design and delivery of interventions. A key aspect of the PCORI approach is engaging stakeholders – including patients, healthcare providers, and advocacy groups or policymakers – in the design and delivery of interventions. Partnering with stakeholders is critical for ensuring that appropriate interventions are designed and successfully disseminated, especially interventions that involve system change. Stakeholders can also play a key role in disseminating the research findings to broader audiences.

Continued Learning

PCORI’s Transitional Care Evidence to Action Network is a learning community designed to promote collaboration among researchers and stakeholders. The goal of the learning community is to enhance the collective impact of the new research PCORI has funded on patient-centered transitional care interventions. Check out their videos and papers to learn more!

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Jess Williams

Associate Professor at The Pennsylvania State University

Jessica A. Williams, PhD, MA is an Associate Professor of Health Policy and Administration at The Pennsylvania State University. Dr. Williams has been a member of the editorial board since 2013. Her research examines how workplace psychosocial factors affect the health and well-being of employees. Specifically, she investigates the role of pain in work disability and well-being. In addition, she researches the utilization of preventive medical services. She holds a Doctorate in Health Policy and Management from the UCLA Fielding School of Public Health, a Master's in Economics from the University of Michigan, Ann Arbor, and a BA in economics from Stanford University.

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