BWH Receives Award from Patient-Centered Outcomes Research Institute to Improve and Reshape Patient Care Transitions

Jeffrey L. Schnipper, MD, MPH, FHM

BWH has been selected to receive a research award from the Patient-Centered Outcomes Research Institute (PCORI) to study the benefits of new models for delivering transitional care from the hospital to home within an Accountable Care Organization structure.

The project, titled "Relative benefits of a hospital-PCMH collaboration within an ACO to improve care transitions," is part of a portfolio of patient-centered comparative clinical effectiveness research that addresses PCORI's National Priorities for Research and Research Agenda. 

BWH will be awarded approximately $1.9 million over three years to fund the research project and is one of only three hospitals in Massachusetts to receive a PCORI grant in this first cycle of primary research funding. The award is still subject to PCORI review and contract finalization.

Jeffrey L. Schnipper, MD, MPH, FHM, director of Clinical Research, BWH Hospitalist Service, will lead the research project at BWH. The project will leverage recent health care reform efforts implemented across Partners HealthCare, such as the creation of Accountable Care Organizations (large medical organizations that take responsibility for lowering costs and improving care for a defined group of patients) and "Patient-Centered Medical Homes" (a new, team-based model of primary care to improve organization and delivery of care, with a focus on chronic disease management).

The study, which will enroll approximately 1,800 patients from BWH and Massachusetts General Hospital, will evaluate a multi-faceted, multi-disciplinary transitions intervention with contributions from hospital and primary-care personnel across 50 primary-care practices as they are converted to Patient-Centered Medical Homes (PCMHs) within the Partners HealthCare Pioneer ACO. The goal is to create a safe transition from the hospital to home that help patients make a full recovery from their illness as quickly as possible.

"Our project is exciting because it takes advantage of recent changes in our health care environment to provide care that is truly seamless and patient-centered. The proposed intervention would not have been possible even five years ago," said Schnipper. "We believe that the results from this study will help health care leaders decide whether and how to adopt specific kinds of interventions, such as a re-design of the patient discharge process, and will provide patients and caregivers with better information to help them decide whether to join medical practices that adopt these new models of care." 

"This marks a major milestone in our work as we build a portfolio of comparative clinical effectiveness research that will provide patients and those who care for them better information about the health care decisions they face," said PCORI executive director Joe Selby, MD, MPH.

"These research projects reflect PCORI's patient-centered research agenda, emphasizing the inclusion of patients and caregivers at all stages of the research."

PCORI is committing $40.7 million in funding for a slate of 25 projects, which were approved by PCORI's Board of Governors following a competitive, multi-stage review process involving scientists, patients, caregivers and other stakeholders. Over 500 proposals were evaluated on the basis of scientific merit, engagement of patients and stakeholders, methodological rigor and fit within PCORI's National Priorities for Research and Research Agenda.