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21. Using HIT to Improve Transitions of Complex Elderly Patients from SNF to Home - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r18hs017817-field-final-report-2012.pdf
    January 01, 2012 - single settings and not follow complex patients as they move between settings leaves older patients discharged … We tested this intervention among adults, aged 65 and older, discharged from skilled nursing facilities … Evaluation We compared a series of measures related to the experiences of patients discharged from … Characteristics of the first 100 discharged patients during the intervention period and the matched … It is clear that older adults discharged from SNFs to home form a highly vulnerable population.

22. Health Information Technoloy in Heart Failure Care - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/k08hs023683-blecker-final-report-2018.pdf
    January 01, 2018 - Furthermore, among patients with heart failure, patients for other causes are less likely to be discharged … The heart failure cohort included patients hospitalized with heart failure who were discharged between … For the CDS cohort, we included all hospitalized patients discharged before March 31, 2018 who had … of heart failure were more likely than patients with a secondary diagnosis of heart failure to be discharged … Partly for this reason, CDS had a small effect in closing the quality gap between patients discharged

23. An Automatic Notification System for Test Results Finalized after Discharge - 2011 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/automatic-notification-system-test-results-finalized-after-discharge/annual-summary/2011
    January 01, 2011 - The study participants were 450 patients who were discharged from the inpatient general medicine and … The study population included patients with TPADs discharged from these services if both their inpatient

24. Stage 3 Meaningful Use: Primary Care Provider Survey (pdf file)
    digital.ahrq.gov/sites/default/files/docs/survey/stage3-mu-primary-care-provider-survey.pdf
    June 16, 2021 - Receiving a summary record with key clinical information when a patient returns from a specialist or is discharged … hospital would… Reconciling key clinical information when a patient returns from a specialist or is discharged … a specialist RECEIVED after the patient sees the specialist RECEIVED after the patient is discharged

25. Scaling Established Clinical Decision Support to Facilitate the Dissemination and Implementation of Evidence-Based Research Findings (R18) | Digital Healthcare Research
    digital.ahrq.gov/funding-mechanism/scaling-established-clinical-decision-support-facilitate-dissemination-and
    January 01, 2023 - successfully adapted and evaluated scaling of the Enhancing Quality of Prescribing Practices for Older Adults Discharged

26. Using Health IT to Improve Care Coordination and Outcomes in Patients with Complex Health Care Needs (pdf file)
    digital.ahrq.gov/sites/default/files/docs/coordination-patients-complex-needs-slides-022014.pdf
    February 20, 2014 - days2 • 50% without medical follow-up2 • Cost to Medicare in 2010: $17.5 billion3 • 19%–23% of discharged … patients suffer an adverse event4 • 36% of discharged patients do not know names or purpose of new … obstructive pulmonary disease, coronary artery disease, hypertension, depression • 21 years + • Discharged … or Usually (n = 150) Baseline Intervention p-value The care transition process for patients discharged … from hospital ► Example: PCPs of patients discharged by hospitalists receive a faxed/e-mailed clinical

27. Value of Technology to Transfer Discharge Information - 2009 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/value-technology-transfer-discharge-information/annual-summary/2009
    January 01, 2009 - During the study, hospitalists discharged 631 patients to their homes. … Aims Compare the benefits of discharge health information technology to usual care in recently discharged

28. Improving Post-Hospital Medication Management of Older Adults with Health Information Technology | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/improving-post-hospital-medication-management-older-adults-health-information
    January 01, 2023 - through an electronic medical record-based transitional care intervention on the care of older adults discharged … This intervention was tested in adults aged 65 and older who had been discharged from the hospital to

29. Improving Management of Test Results that Return After Hospital Discharge - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/k08hs018539-were-final-report-2014.pdf
    January 01, 2014 - Purpose   Nearly half of patients discharged from the hospital with pending test results experience … - Discharge summary is not available: In some rare cases, patients may have been inadvertently discharged … - Patient dies in the hospital or is discharged to hospice: We decided to leave it to the discharging … The goals of this study were to determine: (a) the follow-up patterns of patients discharged from two … from data managers at Regenstrief Institute, we queried INPC data to identify patients who (a) were discharged

30. Telewound Care Network Intervention (Telehealth) Group: Process Guide for Point of Care Providers (pdf file)
    digital.ahrq.gov/sites/default/files/docs/resource/C7_Intervention_Process_Guide_for_Point_of_Care_Nurse.pdf
    June 16, 2021 - The patient will be discharged from TCN when: a. … Once the patient is discharged, mail all forms for patient to Cynthia Scheideman-Miller at 3366 NW Expressway

31. Electronic Medication Adherence Reporting and Feedback During Care Transitions - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/citation/r21hs024587-schnipper-final-report-2019.pdf
    January 01, 2019 - Structured Abstract: Purpose: Implement and evaluate a “smart pillbox” intervention for patients discharged … RAs contacted each subject’s inpatient unit each weekday to identify those being discharged that day. … In a study of post-discharge management of patients with diabetes mellitus discharged on insulin, we … This was for a variety of reasons, but the most common was that the patient was discharged before the … Patients who were being discharged on medications that were too soon to fill could not have previously

32. An Automatic Notification System for Test Results Finalized after Discharge - 2010 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/automatic-notification-system-test-results-finalized-after-discharge/annual-summary/2010
    January 01, 2010 - The study participants are 450 patients who were discharged from the inpatient general medicine and cardiology … Participating physicians’ patients who were discharged from these services and had tests pending during

33. Breathing Easy: Virtual Medication Education for Patients with Chronic Obstructive Pulmonary Disease | Digital Healthcare Research
    digital.ahrq.gov/program-overview/research-stories/breathing-easy-virtual-medication-education-patients-chronic-obstructive-pulmonary-disease
    January 01, 2023 - Patient Transitions Virtual visits with members of a pharmacy team can support patients recently discharged

34. TELE-TOC Telehealth Education Leveraging Electronic Transitions of Care for COPD Patients | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/tele-toc-telehealth-education-leveraging-electronic-transitions-care-copd-patients
    January 01, 2023 - Research Story Virtual visits with members of a pharmacy team can support patients recently discharged … Patient Transitions Virtual visits with members of a pharmacy team can support patients recently discharged

35. The Discharge Assistant: Facilitating Information Transfer at Hospital Discharge (pdf file)
    digital.ahrq.gov/sites/default/files/docs/page/2006Nace_051811comp.pdf
    January 01, 2001 - The Discharge Assistant: Facilitating Information Transfer at Hospital Discharge The Discharge Assistant: Facilitating Information Transfer at Hospital Discharge G. Stephen Nace, M.D. Assistant Professor of Clinical Medicine and Director of Information Technology Department of Medicine University of Illinois Coll…

36. The Effectiveness of an HIT-based Care Transition Information Transfer System to Improve Outpatient Post-Hospital Care for Medically Complex Patients - Final Report (pdf file)
    digital.ahrq.gov/sites/default/files/docs/publication/r18hs017864-ciemins-final-report-2012.pdf
    January 01, 2012 - Scope: Medically complex adults (managing at least two chronic conditions) discharged home from an … Nearly half of patients discharged from the hospital experience at least one medical error in medication … continuity, diagnostic workup, or test follow-up.10 In addition, 19-23% of discharged patients suffer … The medically complex study patients were discharged with many medications (an average of 9.7 – 11 … Baseline Intervention p-value The care transition process for patients discharged from the hospital

37. Schnipper, Jeffrey Lawrence | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/schnipper-jeffrey-lawrence
    September 13, 2018 - sends electronic alerts and reports to patients, caregivers, and primary care providers for patients discharged

38. Creating Online Newborn Intensive Care Unit (NICU) Networks to Educate, Consult & Team - 2009 | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/creating-online-newborn-intensive-care-unit-nicu-networks-educate-consult-team/annual-summary/2009
    January 01, 2009 - health care decisionmaking process, resulting in improved neurological and general health of infants discharged … They conducted semi-structured interviews with parents or caregivers of babies who were discharged from

39. Emory University | Digital Healthcare Research
    digital.ahrq.gov/organization/emory-university
    January 01, 2023 - successfully adapted and evaluated scaling of the Enhancing Quality of Prescribing Practices for Older Adults Discharged

40. Vandenberg, Ann E. | Digital Healthcare Research
    digital.ahrq.gov/principal-investigator/vandenberg-ann-e
    July 24, 2024 - successfully adapted and evaluated scaling of the Enhancing Quality of Prescribing Practices for Older Adults Discharged