# Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care

> **NIH AHRQ K08** · UNIVERSITY OF COLORADO DENVER · 2020 · $128,821

## Abstract

Project Summary/Abstract
This is a revised submission for an AHRQ Mentored Clinical Scientist Research Career Development Award
(K08) by Christine D. Jones, MD, MS. My overall career goal is to develop and implement interventions that
improve patient outcomes through more effective care coordination between clinicians. Care transitions from
hospital to home can be perilous for patients, and fragmented communication contributes to many preventable
adverse events during this transition. Home health care (HHC) is increasingly employed with the intent to
improve care transitions, but even with home support, older adults remain vulnerable to adverse events after
discharge, including hospital readmissions, which contribute to progressive disability for these patients. With
this career development award, I will develop an intervention that improves care coordination between
hospitalists and HHC nurses that aims to reduce adverse patient outcomes, including medication errors and
hospital readmissions.
Candidate and Mentors: I am an Assistant Professor of Medicine at the University of Colorado where I
practice as an adult medicine hospitalist. I completed a research fellowship and have conducted studies to
describe barriers to care coordination, a systematic review of interventions to reduce readmissions, and
analyses of HHC referrals at hospital discharge. I have built productive relationships with my mentors and have
completed two manuscripts – one published, one in press - with my primary mentor, Dr. Frederick Masoudi.
Research and Training: I will build on my prior research through three complementary research and training
aims that will inform an intervention to improve the quality of care coordination between hospitalists and HHC
nurses caring for older adults after acute hospitalization. I will: (1) employ qualitative methods to understand
HHC nurse, patient, and caregiver experiences of care coordination, (2) generate predictive models to identify
modifiable risk factors for 30-day readmissions from HHC within national Medicare data, and (3) develop,
implement, and evaluate a pilot intervention to connect hospitalists and HHC nurses to optimize post-discharge
care coordination and reduce adverse patient outcomes. At award completion, I will have the training and skills
to be a successful independent investigator and will pursue funding for a pragmatic clinical trial to test the
effectiveness of an intervention to improve care coordination between hospitalists and HHC nurses.
Summary: Effective care coordination between hospitalists and HHC nurses is critical to support high-quality
care transitions for vulnerable patients after acute hospitalization. The proposed research will inform an
intervention to improve care coordination between hospitalists and HHC nurses and enhance outcomes for
patients receiving HHC services after hospitalization. This award will support my development into an
independent investigator with expertise in enhancing care co...

## Key facts

- **NIH application ID:** 10015293
- **Project number:** 5K08HS024569-05
- **Recipient organization:** UNIVERSITY OF COLORADO DENVER
- **Principal Investigator:** CHRISTINE D JONES
- **Activity code:** K08 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2020
- **Award amount:** $128,821
- **Award type:** 5
- **Project period:** 2016-09-30 → 2021-11-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10015293

## Citation

> US National Institutes of Health, RePORTER application 10015293, Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care (5K08HS024569-05). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/10015293. Licensed CC0.

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