Improving Care Transitions: Findings from Project ACHIEVE

Project ACHIEVE is funded by the Patient-Centered Outcomes Research Institute (PCORI) and aims to identify which care transition elements are most important to patients and caregivers, what efforts are being implemented across the United States, and finally, which of these programs is producing successful outcomes for patients. In this webinar, Project ACHIEVE key contributors provide details on progress and analysis related to their care transitions research efforts. The speakers note that there has been considerable research conducted on care transitions across disease states; however, these projects lack a focus on what matters to those most impacted by illness and the state of care given by our health systems and providers. Investigators discuss themes common throughout their analyses of patient and caregiver data, including a need for collaborative discharge planning, a desire for actionable information and a preference for consistent providers across settings. The webinar includes a slide speaking to how providers can help to address identified gaps and a discussion about key findings resulting from retrospective analysis of readmissions and hospital care transitions program implementation data. A question and answer session is included. The COPD Foundation’s Bill Clark and Kristen Willard sat on the Stakeholder Advisory Group for this project.