# An equity-focused intervention to improve care transitions for Medicaid insured individuals with co-occurring serious mental health

> **NIH AHRQ R18** · UNIVERSITY OF PENNSYLVANIA · 2024 · $500,000

## Abstract

Project Summary
People insured by Medicaid with a co-occurring serious mental illness (i.e., depression, schizophrenia, and
bipolar disorder) experience persistent and growing disparities following medical hospitalizations and
interventions that focus on their transitional care needs are lacking. Our study focuses on the adaptation of the
THRIVE, an equity-focused evidenced based intervention that supports Medicaid-insured individuals with
multiple chronic conditions transitioning from hospital to home. THRIVE services include coordinating care,
standardizing interdisciplinary communication, and addressing unmet clinical and social needs following hospital
discharge. While evidence suggests robust improvements in post-discharge outcomes for THRIVE participants,
it remains unclear whether the interventions equally benefit patients with and without SMI. The goals of this
project are to adapt, implement and evaluate THRIVE to ensure suitability for all patients insured by Medicaid
including those with co-occurring SMI. To meet this goal, we propose the conduct of a Type I Hybrid
effectiveness-implementation stepped wedge cluster randomized controlled trial (CRCT)15 at a new site, the
Hospital of the University of Pennsylvania Cedar Campus (HUP-Cedar). HUP-Cedar is a 100-bed minority
serving hospital located in West Philadelphia where >50% of patients are Medicaid or dually Medicare and
Medicaid-insured. This study represents a three-way partnership among health services researchers, community
advisors, and health care leadership and staff at HUP-Cedar and Penn Medicine at Home and seeks as its
primary objective to leverage participatory methods to adapt the THRIVE intervention and evaluate the context
required for implementation. A second objective for this study is to examine differences in the utilization outcomes
(e.g., readmissions) between THRIVE participants with SMI compared to those receiving usual care. Finally, we
will employ mixed methods approaches through participant and clinician interviews and surveys to evaluate the
acceptability, appropriateness, feasibility and cost of the intervention. Our study and engagement with community
and health system partners is informed equity centered frameworks that will help to emphasize the systems,
policies and delivery process from which inequities might arise. If our study hypotheses are supported, we will
identify not only if an equity-oriented evidence-based intervention can be adapted and implemented to meet the
needs of Medicaid insured patients including those with SMI, but we will also uncover the factors associated with
those results. Our proposal is well-aligned with AHRQ's goal to develop and adapt EFEBI's that prioritize the
voices and needs of the most underserved populations and change care processes to accelerate equity within
healthcare systems. Collectively, the results of this study will provide the foundation for the next phase of our
research, which includes a multi-site evaluati...

## Key facts

- **NIH application ID:** 10928231
- **Project number:** 5R18HS029815-02
- **Recipient organization:** UNIVERSITY OF PENNSYLVANIA
- **Principal Investigator:** JACQUELINE MARGO BROOKS CARTHON
- **Activity code:** R18 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2024
- **Award amount:** $500,000
- **Award type:** 5
- **Project period:** 2023-09-30 → 2026-09-29

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10928231

## Citation

> US National Institutes of Health, RePORTER application 10928231, An equity-focused intervention to improve care transitions for Medicaid insured individuals with co-occurring serious mental health (5R18HS029815-02). Retrieved via AI Analytics 2026-05-24 from https://api.ai-analytics.org/grant/nih/10928231. Licensed CC0.

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