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201. Coordinating Transitions: HIT Role in Improving Multiple Chronic Disease Outcomes - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs02257502-hewner-final-report-2017.pdf
     January 01, 2017 - Reliance on the recovering patient to convey information across settings during the transition from … A multidisciplinary approach to transition care: A patient safety innovation study. … A population-based care transition model for chronically ill elders.

202. Field, Terry | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/field-terry
     January 01, 2023 - Field, Terry A pilot health information technology-based effort to increase the quality of transitions from skilled nursing facility to home: compelling evidence of high rate of adverse outcomes. Citation Donovan JL, Kanaan AO, Gurwitz JH, et al. A pilot health information tec…

203. Gurses, Ayse Pinar | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/gurses-ayse-pinar
     January 01, 2023 - Gurses, Ayse Pinar Work system barriers and facilitators of a team health information technology. Citation Hose BZ, Carayon P, Hoonakker PLT, Brazelton TB 3rd, Dean SM, Eithun BL, Kelly MM, Kohler JE, Ross JC, Rusy DA. Work system barriers and facilitators of a team health inf…

204. Eisenstein, Eric | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/eisenstein-eric
     January 01, 2023 - Eisenstein, Eric Improving Care Transitions for Complex Patients through Decision Support - Final Report Citation Eisenstein E. Improving Care Transitions for Complex Patients through Decision Support - Final Report. (Prepared by Duke University under Grant No. R18 HS017795). …

205. A National Web Conference on Transitions in Care | Digital Healthcare Research
     digital.ahrq.gov/events/national-web-conference-transitions-care
     January 01, 2023 - This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://digital.ahrq.gov/contact-us . Let us know th…

206. Information Needs of Homecare Nurses During Admission and Care Planning - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r01hs024537-sockolow-final-report-2020.pdf
     January 01, 2020 - Problems exist with information transfer during the transition to HHC(5, 8, 10- 15) and HHC clinicians … The Joint Commission defines accurate communication of medication information across the transition … Getting to complete and accurate medication lists during the transition to home health care. … Hospital to nursing home transition challenges: perceptions of nursing home staff. … Transition to home care: Quality of mental health, pharmacy, and medical history information.

207. Holomua Project Improving Transitional Care in Hawaii | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/holomua-project-improving-transitional-care-hawaii
     January 01, 2023 - Holomua Project Improving Transitional Care in Hawaii Project Final Report ( PDF , 228 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No…

208. Hewner, Sharon | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/hewner-sharon
     September 26, 2019 - Hewner, Sharon A clinical classification framework for identifying persons with high social and medical needs: The COMPLEXedex-SDH. Citation Sullivan SS, Ledwin KM, Hewner S. A clinical classification framework for identifying persons with high social and medical needs: The CO…

209. Visiting Nurse Service of New York | Digital Healthcare Research
     digital.ahrq.gov/organization/visiting-nurse-service-new-york
     January 01, 2023 - Visiting Nurse Service of New York Development of Dashboards to Provide Feedback to Home Care Nurses Description This project designed and conducted a usability evaluation of dashboards that provide feedback to home care nurses to improve the care of patients with chronic hear…

210. Sakuda, Christine M. | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/sakuda-christine-m
     January 01, 2023 - Sakuda, Christine M. Improving transitional care in Hawaii: opening communication between community-based and tertiary-care healthcare providers. Citation Chin BJ, Sakuda CM, Balaraman V. Improving transitional care in Hawaii: opening communication between community-based and …

211. Jain, Anjali | Digital Healthcare Research
     digital.ahrq.gov/principal-investigator/jain-anjali
     January 01, 2023 - Jain, Anjali Improving sickle cell transitions of care through health information technology. Citation Frost JR, Cherry RK, Oyeku SO, et al. Improving sickle cell transitions of care through health information technology. Am J Prev Med 2016 Jul;51(1 Suppl 1):S17-23. PMID: 2732…

212. Improving Medication Management Practices and Care Transitions through Technology | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/improving-medication-management-practices-and-care-transitions-through
     January 01, 2023 - Improving Medication Management Practices and Care Transitions through Technology Project Final Report ( PDF , 294.76 KB) Disclaimer Disclaimer The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily …

213. Telemedicine System | Digital Healthcare Research
     digital.ahrq.gov/technology/telemedicine-system
     January 01, 2020 - to reduce medication-related issues among patients during the hospital-to-skilled nursing facility transition

214. Virtual Pharmacy Improves Medication Use and Patient Safety in Palliative Care | Digital Healthcare Research
     digital.ahrq.gov/program-overview/research-stories/virtual-pharmacy-improves-medication-use-and-patient-safety-palliative-care
     January 01, 2023 - Virtual Medication Education for Patients with Chronic Obstructive Pulmonary Disease The Telehealth Transition

215. Patient-Centered Care | Digital Healthcare Research
     digital.ahrq.gov/health-care-theme/patient-centered-care
     January 01, 2023 - A Randomized Clinical Trial of Smartphone Virtual Reality for Pain Management During Burn Care Transition

216. Safer Inter-Hospital Transfers by Improving Access to Health Information | Digital Healthcare Research
     digital.ahrq.gov/program-overview/research-stories/safer-inter-hospital-transfers-improving-access-health
     January 01, 2023 - A better transition improves patient safety Inter-hospital transfer is a common occurrence among patients

217. USA, WA, Seattle | Digital Healthcare Research
     digital.ahrq.gov/location/usa-wa-seattle
     January 01, 2023 - to reduce medication-related issues among patients during the hospital-to-skilled nursing facility transition

218. Care Coordination Enabled by Health Information Technology: What Will It Take? | Digital Healthcare Research
     digital.ahrq.gov/ahrq-funded-projects/care-coordination-enabled-health-information-technology-what-will-it-take
     January 01, 2023 - The care coordination objectives included dashboards to track patient referrals in real time, a care transition

219. Goetz Goldberg D, Kuzel AJ, Feng LB, et al. "EHRs in primary care practices: benefits, challenges, and successful strategies." | Digital Healthcare Research
     digital.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit/research/goetz-goldberg-d-kuzel
     January 01, 2023 - communication and training for employees and physicians, alternative strategies for patient care during transition

220. Patient Self Monitoring to Transfer Physical Therapy Exercise from Clinic to Home - Final Report (pdf file)
     digital.ahrq.gov/sites/default/files/docs/citation/r21hs021733-sheehan-final-report-2014.pdf
     January 01, 2014 - Attention to the transition of PT prescribed exercise from clinic to home is important for the following … and at home to aid in monitoring the correctness of exercise at home and thereby facilitating the transition … acceptance by clinicians and patients demonstrate the potential value of the IBEHR for helping patients transition