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Better science to support better outcomes

Clinical trials and comparative effectiveness studies have consistently demonstrated the TCM’s health and economic benefits, including reduced re-hospitalization and health care expenditures. Having established a solid knowledge base for the TCM in at-risk hospitalized elderly patients, we have adapted the model to include other settings and other populations. Working with nurses, physicians, health systems leaders, payers, and policymakers, we have tested complex interventions and fostered quality and financial incentives to implement the model. Learn more about our ongoing efforts to improve health and quality outcomes.

Hospital to Home
Translational and Implementation
Hospitalized Cognitively Impaired Older Adults
Primary Care
Long-Term Services and Supports
Family Caregivers

The TCM research team is one of five collaborating research teams on this ground-breaking effort.

Project ACHIEVE, a PCORI initiative to improve transitional care programs and outcomes from a patient and family perspective is a multi-institutional

study to determine which evidence-based transitional care components and/or clusters most effectively produce patient and caregiver desired outcomes overall and among diverse patient and caregiver populations in different healthcare settings.Using the results, we will develop concrete, actionable recommendations regarding how best to implement these strategies. This work will provide tools for hospitals, community-based organizations, patients, caregivers, clinicians and other stakeholders to help them make informed decisions about which strategies are most effective and how best to implement them in their communities.