D&I

Building Capacity for Dissemination and Implementation to Maximize Research Impact in a CTSA: The University of Wisconsin Story

Building Capacity for Dissemination and Implementation to Maximize Research Impact in a CTSA: The University of Wisconsin Story

The publication reports results of an 8-year process of stakeholder engagement aimed at building capacity in Dissemination and Implementation (D&I) research at the University of Wisconsin as part of the National Institutes of Health’s Clinical and Translational Science Award (CTSA). HIP Investigators, Dr. Andrew Quanbeck and Dr. Maureen Smith et al. describe how CTSA leaders at UW built a comprehensive system designed to improve the health of the communities statewide by incorporating D&I concepts across the translational research spectrum.

The team also developed a toolkit on HIPxChange that describes resources and activities developed to build D&I capacity at UW’s Institute for Clinical and Translational Research.

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HIP Model

A practical model for research with learning health systems: Building and implementing effective complex case management

A practical model for research with learning health systems: Building and implementing effective complex case management

For researchers to contribute meaningfully to the creation of learning health systems, practical tools are required to operationalize existing conceptual frameworks. A team of authors including HIP Investigators, Dr. Maureen Smith and Dr. Menggang Yu describe a model currently in use by the University of Wisconsin Health Innovation Program (HIP). The HIP model consolidates and enhances existing learning health system frameworks by defining specific steps needed to create sustainable change based on research conducted within the health system.

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View the Case Management Case Management Benefit Scoring System Toolkit

Big Data Word Scramble

The Importance of Health Insurance Claims Data in Creating Learning Health Systems: Evaluating Care for High-Need High-Cost Patients Using the National Patient-Centered Clinical Research Network (PCORNet)

The Importance of Health Insurance Claims Data in Creating Learning Health Systems: Evaluating Care for High-Need High-Cost Patients Using the National Patient-Centered Clinical Research Network (PCORNet)

Case management programs for high-need high-cost patients are spreading rapidly among health systems. PCORNet has substantial potential to support learning health systems in rapidly evaluating these programs, but access to complete patient data on health care utilization is limited as PCORNet is based on electronic health records not health insurance claims data. Because matching cases to comparison patients on baseline utilization is often a critical component of high-quality observational comparative effectiveness research for high-need high-cost patients, limited access to claims may negatively affect the quality of the matching process. A team of authors including HIP Investigators Dr. Maureen Smith and Dr. Menggang Yu sought to determine whether the evaluation of programs for high-need high-cost patients required claims data to match cases to comparison patients.

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NNT vs number referred

Training and Interpreting Machine Learning Algorithms to Evaluate Fall Risk After Emergency Department Visits

Training and Interpreting Machine Learning Algorithms to Evaluate Fall Risk After Emergency Department Visits

Machine learning is increasingly used for risk stratification in health care. Achieving accurate predictive models do not improve outcomes if they cannot be translated into efficacious intervention. HIP Investigator, Dr. Brian Patterson et al. examined the potential utility of automated risk stratification and referral intervention to screen older adults for fall risk after emergency department visits. This study evaluated several machine learning methodologies for the creation of a risk stratification algorithm using electronic health record data and estimated the effects of a resultant intervention based on algorithm performance in test data.

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Patient using tablet

Inpatients Sign On: An Opportunity to Engage Hospitalized Patients and Caregivers Using Inpatient Portals

Inpatients Sign On: An Opportunity to Engage Hospitalized Patients and Caregivers Using Inpatient Portals

Inpatient portals are online patient portals linked to electronic health records that provide hospitalized patients and caregivers secure access to real-time clinical information and tools to enhance their communication with providers and hospital experience. HIP Investigator, Dr. Ryan Coller et al. provided a perspective that inpatient portals are innovative tools poised to engage patients and caregivers during hospitalization and, thus, enhance patient-centered care. This article highlights the potential of using inpatient portals to engage hospitalized patients and caregivers and proposes next steps to evaluate this emerging technology.

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Veteran Engagement

Development of a veteran engagement toolkit for researchers.

Development of a veteran engagement toolkit for researchers.

Engaging patients in the planning, implementation and dissemination of research can increase the credibility and relevance of results and lead to higher quality, more patient-centered care. Veterans have unique experiences and healthcare needs, making their input on research related to their care particularly important. However, existing veteran engagement resources primarily focus on veterans who receive care through the Veterans Health Administration (VA). This excludes those veterans - the majority - who do not use the VA for healthcare.

To address the gap Dr. Nasia Safdar, Nicole Brys, and Dr. Jeff Whittle developed a veteran engagement toolkit that was informed by the work of both VA and non-VA researchers across the USA.

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Doctor with patient

Inpatient Portals for Hospitalized Patients and Caregivers: A Systematic Review.

Inpatient Portals for Hospitalized Patients and Caregivers: A Systematic Review.

Patient portals, web-based personal health records linked to electronic health records (EHRs), provide patients access to their healthcare information and facilitate communication with providers. A team of authors, including HIP Investigator Dr. Ryan Coller, conducted a systematic review of the literature evaluating the design, use, and impact of inpatient portals, which are patient portals designed to give hospitalized patients and caregivers inpatient EHR clinical information for the purpose of engaging them in hospital care.

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Checking blood pressure

Connecting rheumatology patients to primary care for high blood pressure

Connecting rheumatology patients to primary care for high blood pressure

High blood pressure is the most prevalent cardiovascular risk factor for rheumatology patients, yet blood pressures are not frequently addressed in specialty visits. Dr. Christie Bartels et al. developed the BP Connect Health protocol to address this issue by training medical assistants and nurses to (1) re-check high blood pressures, (2) advise patients about the link betweeen rheumatic and cardiovascular diseases, and (3) connect patients with timely primary care follow-up using electronic health record orders. In an analysis of the intervention, investigators found that the odds of timely primary care follow-up doubled and the media time to follow-up declined by nearly half, from 71 to 38 days. Additionally, the number of rheumatology visits with high blood pressure declined from 17% to 8% in the 2 years after the protocol was implemented, which suggests that the protocol resulted in population-level declines in high blood pressure. A free toolkit with the BP Connect Health protocol and tools to successfully implement it is available on HIPxChange here.

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happy people surrounding happy baby in hospital

A family-centered rounds checklist, family engagement, and patient safety

A family-centered rounds checklist, family engagement, and patient safety

In a recent randomized clinical trial led by Dr. Elizabeth Cox, implementing a checklist during family-centered rounds increased family engagement and the safety of hospitalized children from the perspective of the families. The checklist was developed with input from the hospital staff and families of hospitalized children, and two items were found to significantly increase family engagement: when hospital staff read back orders, families engaged in more decision-making and provided more information, and families were also more engaged when the team talked about goals for discharge. The materials needed to implement the family-centered rounds checklist in are available in a free toolkit here.

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C-TraC Nurse on Phone with Patient

Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

Low-cost transitional care with nurse managers making mostly phone contact with patients cut rehospitalization at a VA hospital

The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among patients with high-risk conditions discharged to community settings from the hospital. Patients in the C-TraC program experienced one-third fewer rehospitalizations than those in the comparison group and there was an estimated savings of $1,225 per patient. This model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or constrained resources. A toolkit with the C-TraC protocol is available on HIPxChange here.

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