Project ACHIEVE 
(Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence)

Funded by Patient Centered Outcome Research Institute (PCORI), nationally recognized leaders in health care and research methods are partnering with patients and caregivers to evaluate the effectiveness of current efforts at improving care transitions and develop recommendations on best practices for patient-centered care transitions and guidance for spreading them across the U.S.

Patients in the U.S. suffer harm too often as they move between sites of health care, and their caregivers
experience significant burden. Unfortunately, the usual approach to health care does not support continuity and coordination during such “care transitions” between hospitals, clinics, home or nursing homes. Poorly managed patient care transitions can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and ER visits.

Specific Aims:
1. Identify the transitional care outcomes and components that matter most to patients and caregivers.
2. Determine which evidence-based transitional care components (TCCs) or combinations of components most effectively yield patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different types of care settings and communities.
3. Identify barriers and facilitators to the implementation of specific TCCs or combinations of TCCs for different types of care settings and communities.
4. Develop recommendations for dissemination and implementation of the findings on the best evidence regarding how to achieve optimal TC services and outcomes for patients, caregivers and providers.

Study Design:
Capitalizing on the opportunity for a natural experiment observational study, the research team will conduct qualitative and quantitative studies. This five-year study is divided into two distinct phases. During the first phase, Project ACHIEVE will use focus groups--with patients, caregivers, providers--and hospital site visits to identify the transitional care outcomes and service components that matter most to patients. In this first phase, the team will refine and validate outcome assessment instruments and secure commitments from institutions and community-based organizations participating in the study. During the second phase, the team will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S.

Outcomes and Impact:
Through rigorous study and evaluation, Project ACHIEVE will:
1) Identify best practices in care transitions that matter most to patients and their caregivers, and reduce excess emergency department and hospital utilization.
2) Develop a toolkit to guide informed decisions and spread these best practices across the U.S.
3) Develop Care Transitions Surveys that can standardize evaluation of patients’ and caregivers’ experience with care transitions.

Collaborating organizations:
Westat, University of Pennsylvania, Boston Medical Center, Telligen, Kaiser Permanente Southern California, Health Research & Educational Trust, Joint Commission Resources, Essential Hospitals Institute, National Association of Area Agencies on Aging, Caregiver Action Network, United Hospital Fund, Project Patient Care, Louisiana State University Health Sciences Center, University of Illinois at Chicago

Project ACHIEVE Overview and Interim Findings