Improving care coordination for patients with complex health needs
Implementing personalized cross-sector transitional care management to promote care continuity, reduce low value utilization, and reduce the burden of treatment for high-need, high-cost patients
This study is working to improve the support for patients with multiple health issues and social challenges by creating better care plans that connect medical and community services, making it easier for everyone involved to work together and help you stay healthy during transitions between different types of care.
Quick facts
| Grant type | R01 grant |
|---|---|
| Study type | NIH-funded research |
| Funding institution | State University of New York at Buffalo NIH-funded |
| Lab location | 1 site (Amherst, United States) |
| Project ID | NIH-11070299 on NIH RePORTER |
What this research studies
This research focuses on enhancing the transitional care for high-need, high-cost patients who often face multiple chronic conditions and social challenges. By collaborating with service providers outside the healthcare sector, the project aims to create comprehensive care plans that address both medical and social needs. The approach includes using health information technology to ensure seamless communication and coordination among care providers, ultimately aiming to reduce unnecessary healthcare utilization and improve patient outcomes. The study will refine existing interventions to better support these vulnerable patients during transitions between different care settings.
Who could benefit from this research
Good fit: Ideal candidates for this research are patients with multiple chronic conditions, functional disabilities, or significant social needs requiring intensive care coordination.
Not a fit: Patients with stable health conditions or those who do not require transitional care services may not benefit from this research.
Why it matters
Potential benefit: If successful, this research could lead to improved care continuity and reduced healthcare burdens for patients with complex health needs.
How similar studies have performed: Previous research has shown success in improving care transitions through health information exchange, indicating a promising foundation for this approach.
Where this research is happening
Amherst, United States
- State University of New York at Buffalo — Amherst, United States (Active)
Researchers
- Principal investigator: Hewner, Sharon — State University of New York at Buffalo
- Study coordinator: Hewner, Sharon
About this research
- This is an active NIH-funded research project — typically early-stage science, not a clinical trial accepting patient enrollment.
- Some NIH-funded labs run parallel clinical studies or seek volunteers for related work. To check, contact the principal investigator or institution listed above.
- For full project details, budget, and progress reports, visit the official NIH RePORTER page below.