In Care Transitions, a Chance to Make or Break Patients' Recovery

This Patient-Centered Outcomes Research Institute (PCORI) article describes PCORI-funded research efforts aimed at improving transitions in care. Several initiatives are referenced and hyperlinked in the article for further reading; particular focus is paid to one examining transitional care in rural areas and another in urban environments. In the former project, ROADMAP, researchers are approaching the obstacle of physical distance between patients and health resources (and often resulting compromised communication) by testing the effectiveness of an intervention connecting patients to their local resources. The other highlighted initiative, PArTNER, is based in an urban setting and is examining obstacles to successful transitions in racial and ethnic minorities and patients of low socioeconomic status. Patients receiving the study intervention (designed by researchers, patients and focus group participants as well as partner organizations, including the COPD Foundation) will be assigned a patient navigator to support them while hospitalized and after returning home.