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AHRQ--Agency for Healthcare Research and Quality: Advancing Excellence in Health Care

Topic Suggestion Description

View Topic Suggestion Disposition (PDF) 72 kB

Date submitted: July 26, 2011

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
For Rehab patients, what is the comparative effectiveness of a coordinated primary health care team following the patient with the usual care of hospitalization to home health>
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
I would like to compare a team consisting of a primary care physician, nurse practitioner and social work (continuum of care team) that follows the patient through an episode of care that involves rehab with the typical method used today of hospitalization transferred to rehab and transferred to home with home health.
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Although this study does apply to patients that are younger that 65, I would like a special focus on those 65 and older with a hip or knee surgery.
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
We could have two subgroups - younger than 65 and 65 and older. I would also cohort the hips and knees.
The control group would be the ones receiving the continuum of care service.
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
Re-admissions and/or visits to the ED would be diminished therefore saving money.
We would also like to see if rehab is completed faster since there would be not delay in service and a stronger support system.
Describe any health-related risks, side effects, or harms that you are concerned about.
The main concern would be that the "team" would follow-up in the home, most likely one at a time, however, the patient would have to agreed to be followed like this. So far, our experience with this model has been good.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Arthritis and nontraumatic joint disorders
  • Functional limitations and disability
AHRQ Priority Populations
  • Elderly
  • Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care
Federal Health Care Program
  • Medicare


Describe why this topic is important.
The care received by patients lacks continuity across the continuum. We are able to fill this gap however, it needs further research.
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
We have a Continuum of Care team that provides this level of support with great success but have found funding to be limited. We would like an opportunity to prove that our outcomes are substantial. We also need more data about patients who do not receive this type of care to make the comparison truly effective.
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
If yes, please explain:
I don't think so because the aim to to design a model that moves the patient back to their home with little or no health care problems for their rehab episode.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
We hope to be able to design a model that is sustainable and replicatable in most areas. The reason I say "most" is because we are in a high volume city, so we do have staff to support the model.
Describe the timeframe in which an answer to your question is needed.
We would like an answer by the end of the year however, funding will govern our abilities to do so.
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
Based on our experience, the frail, vulnerable elderly are frequently unable to follow directions and ask for clarification due to the feeling of medicine being the authority. With support and having an extra set of eyes and ears, advocating for this type of patient, we can help them navigate the healthcare system with good results.

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Researcher
Are you making a suggestion as an individual or on behalf of an organization?
Organization - Motion Picture & Television Fund
Please tell us how you heard about the Effective Health Care Program
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