UK HealthCare

University of Kentucky Approved to Lead $14.9 Million Research Project to Study Care Transitions


LEXINGTON, Ky. (Oct. 8, 2014) – The University of Kentucky has been approved to lead a $14.9 million project from the Patient-Centered Outcomes Research Institute (PCORI) to identify the most effective approaches for patient care transitions as they move between hospitals, nursing homes and their own homes.

PCORI, an independent, non-profit organization authorized by Congress as part of the Patient Protection and Affordable Care Act, approved this week a recommendation for UK's Dr. Mark V. Williams, director of the Center for Health Services Research, to lead a three-year contract for one of PCORI's priority projects, "Effectiveness in Transitional Care."

"The expert faculty and staff at the University of Kentucky are committed to improving the well-being of the communities and people they touch and teach," said President Eli Capilouto. "UK's new $14.9 million contract will help improve research and understanding of outcomes in the patient transition process and translate new knowledge into application. It's how we help shape better outcomes along the spectrum of patient care." 

Poorly managed patient care transitions between hospitals, clinics, home or nursing homes can lead to worsening symptoms, adverse effects from medications, unaddressed test results, failed follow-up testing, and excess rehospitalizations and ER visits, said Williams, who is also professor of internal medicine and health policy and management at UK.

Patients in the U.S. suffer harm too often as they move between sites of health care, and their caregivers experience significant burden, he said. Unfortunately, the usual approach to health care does not support continuity and coordination during such “care transitions” between hospitals, clinics, home or nursing homes.

“Through kynect and Medicaid expansion, hundreds of thousands of Kentuckians who were previously uninsured now have access to health care services. Greater access was a critical first step in improving Kentucky’s dismal health rankings," said Cabinet for Health and Family Services Secretary Audrey Tayse Haynes. "Now we must ensure quality, coordination and continuity of care as patients receive health care services, transition between providers, and return home. This project will help identify best practices for transitional care, which will play a pivotal role in improving health care outcomes in Kentucky.”

The study, Project ACHIEVE (Achieving Patient-Centered Care and Optimized Health In Care Transitions by Evaluating the Value of Evidence), combines the expertise of patients, caregivers and stakeholders with national leaders in care transition research.

It will identify which combination of transitional care services improve outcomes that matter most to patients and their caregivers as they leave the hospital and return to their homes. Patient characteristics, care settings, and other factors will be incorporated in the analysis to determine which transitional care services work best for whom and under what circumstances.

"Receiving this contract from PCORI to lead this project is a testament to the outstanding work being done by a very capable and expert team at the University of Kentucky," said Dr. Michael Karpf, UK executive vice president for health affairs.  "Care transitions can be a challenge for patients, their families and providers and this project will give evidence-based information on how we can make significant improvements and impact in this area."

The goal is for Project ACHIEVE to determine which transitional care services most effectively produce patient and caregiver desired outcomes among diverse patient and caregiver populations in different health care settings, Williams said.

Using the results, the project team will develop concrete, actionable recommendations regarding how best to implement strategies and 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.

"Each year more than 33 million Americans make this difficult journey from the hospital bed to the post-acute setting to home and community-based care and, all too often, back again.  Various strategies for improving care transitions are being tested across the country, but no one has yet determined which strategy works best, for whom, and under what circumstances," said Glen P. Mays, Ph.D., Scutchfield Endowed Professor in Health Services and Systems Research in the UK College of Public Health. "Our team will bring together the best possible data and analytic methods to answer these questions. From public health and economic perspectives, there is no health care delivery quandary more important to solve than this one."

The project team will identify which transitional care services and outcomes matter most to patients and caregivers, evaluate comparative effectiveness of ongoing multi-component efforts at improving care transitions, and develop recommendations on best practices for the design, implementation and large-scale national spread of highly effective, patient-centered care transition programs.

This collaborative team includes experts in statistics, surveys, implementation science, and quality improvement from 14 organizations including UK, University of Pennsylvania, Boston Medical Center, Telligen, Westat and Kaiser Permanente.

“This new round of funding not only adds several innovative studies to our growing portfolio of patient-centered outcomes research, but also reflects our progress toward funding bigger, larger studies on specific high-impact, high-burden topics, such as obesity treatment and transitional care,” said PCORI Executive Director Dr. Joe Selby. “As we increasingly focus on specific high-priority topics and larger pragmatic studies, we continue to benefit from and seek insightful proposals initiated by both researchers and the broader healthcare community.”

This three-year study is divided into two phases. During the first phase, Project ACHIEVE will use focus groups and site visits to identify the transitional care outcomes and service components that matter most to patients. During the second phase, the team will evaluate the comparative effectiveness of multi-component care transitions programs occurring across the U.S. The project team will evaluate studying historical and current and future groups of patients, caregivers and providers using site visits, surveys, and clinical and claims data.

The award has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract to UK. PCORI has approved nearly $671 million to support 360 research studies and initiatives since it began funding research in 2012. For more information about PCORI funding, visit

In 2013, Debra Moser, professor at the UK College of Nursing, was awarded $2.1 million over three years from PCORI to advance her research in risk-reducing interventions for cardiovascular disease in Kentucky’s Appalachian region.

MEDIA CONTACT: Kristi Lopez, 859-806-0445,