U.S. Department of Health and Human Services: Improving Individual and Family Outcomes through Continuity and Coordination of Care in Hospice (R01 Clinical Trial Optional)
The Improving Individual and Family Outcomes through Continuity and Coordination of Care in Hospice initiative seeks to stimulate research that focuses on reducing negative individual and family outcomes related to unwanted care facility transitions at the end of life and optimize the individual and family outcomes related to high quality coordination of care of care of individuals who are enrolled in hospice. The initiative emphasizes individuals who are receiving hospice care and their family caregivers, in any setting where hospice care is provided, including their home, a relative’s home, a hospice inpatient facility, an assisted living facility, a short- or long-term care facility, or a hospital.
Research projects of interest include, but are not limited to studies that:
- Identify the outcomes of individuals and families who have experienced a transition between hospice settings or have been discharged from hospice including, but not limited to; 1) whether the transition was desired; 2) where they receive care; 3) whether their advance care plans are communicated; and 4) whether their care goals and values are honored during and after the transition.
- Identify which patient- and family-centered outcomes are most important to achieve goal-concordant care during and after transitions across hospice settings or out of hospice, across populations.
- Determine the factors that affect patient and family decision-making about goals of care that lead to unwanted transitions across settings within hospice, or out of hospice.
- Identify reasons for live discharge from hospice to inform development of interventions that address patient-, family-, and clinician-centered reasons for transfer out of hospice.
- Understand the discharge process and the care coordination across teams and agencies of key factors in the plan of care that affect patient- and family-centered outcomes.
- Design, implement, and evaluate interventions and models of care that facilitate communication of the individual’s preferences including those that: 1) optimize communication of advance care planning across transitions to improve continuity of care and care coordination; 2) facilitate tracking of patient- and family-centered goals of care (e.g., advance care plans, advance directives) across settings in a way that encourages goal-concordant care in all settings; and 3) facilitate transfer of Electronic Health Records (EHR) across settings to clarify patient- and family-centered goals of care and desired outcomes.
- Determine what factors affect the decision for a transition across settings within or out of hospice, to inform design of interventions to prevent unwanted transitions, especially how these factors may differ in diverse populations.
- Develop and test interventions that address factors leading to discrepancies in transition outcomes such as demographics, organization of the hospice, disease state, etc.
- Assess the effect of organizational variables (such as whether the hospice is for-profit, non-profit, independent, part of a vertically or horizontally integrated health care system) on patient- and family-centered outcomes to inform development of interventions to address the discrepancies in transition outcomes across hospices and geographic regions.
- Design and test models of care that provide consistency in goals of care across settings to minimize burden on patient and family caregivers.
- Evaluate whether well-designed and effective transition programs can be adapted and implemented in different hospice or health care systems to minimize unwanted transitions and improve care coordination.
Amount: Application budgets are not limited but need to reflect the actual needs of the proposed project. The project period is for up to five years. Note: Applicants requesting $500,000 or more in direct costs in any year (excluding consortium F&A) must contact a Scientific/Research Contact at least 6 weeks before submitting the application and follow the Policy on the Acceptance for Review of Unsolicited Applications that Request $500,000 or More in Direct Costs as described in the SF424 (R&R) Application Guide.
Eligibility: Special district governments; for profit organizations including small businesses; Native American tribal organizations; independent school districts; nonprofit organizations with or without 501(c)(3) status; city or township governments; institutions of higher education; county governments; public housing authorities/Indian housing authorities; state governments; and others.
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