AHRQ – Improving Quality of Care and Patient Outcomes During Care Transitions (R01)

December 11, 2019 by dld5dt@virginia.edu


The purpose of this Funding Opportunity Announcement (FOA) is to invite applications to produce health services research that will rigorously test promising interventions aimed at improving communication and coordination during care transitions.


Transitions of care are the movements of patients between providers or clinical settings which typically occur when primary care providers refer patients to specialty care, or when patients are discharged from the hospital to subsequent care settings. During care transitions, critical information aimed to improve the patient’s condition and health outcomes needs to be accurately communicated and coordinated between health professionals, the patient, and the family to ensure that safe, high-quality care is provided and care continuity is maintained.

Poorly managed transitions can lead to costly, unsafe, and low quality health care. The Centers for Medicare & Medicaid Services (CMS) notes that Medicare patients typically experience multiple provider transfers during post-acute care at a cost to the U.S. health care system of approximately $15 billion per year (CMS, 2018). In particular, people with multiple chronic conditions (MCC) undergo many care transitions across settings and providers and are particularly at risk for avoidable adverse events during these many transitions. MCC patients are high cost, high need patients that account for 65% of health care spending and mitigating their risks during care transitions has the potential to greatly reduce care costs and improve care quality. Additionally, uncoordinated care transitions result in unneeded stress and burden on patients and caregivers as well as considerable burden on clinicians who don’t have the necessary information to deliver high quality care and must expend a great deal of effort to obtain this information.

Applying innovative patient-centric solutions into the transitional care management process has the potential to improve care transitions by enhancing communication and coordination, thereby reducing duplicate services and mitigating adverse events. New and improved health information technology solutions can facilitate an integrated multi-disciplinary approach to improving care transitions by defragmenting information, improving communication, and assuring the care team and other stakeholders have access to reliable and complete health information that may be located in other care settings or disparate systems.  Additionally, these solutions have the capability to empower providers, patients, and caregivers in sharing the responsibility of improving health outcomes while reducing adverse events and costs.

Health Services Research on using innovative patient-centric solutions to improve care transitions aligns with the Department of Health and Human Services (DHHS) goals to increase the value derived from health care spending while delivering whole person 360 degree care. Developing effective approaches to care coordination across care transitions will also support the aims of reducing burden on patients, their caregivers, and clinicians. Furthermore, this announcement will support proposed regulatory efforts to create a more interoperable health care system that improves patient access to their electronic health information, seamless and secure data exchange, and enhanced care coordination.

Key Dates

Posted Date: December 4, 2019
Open Date (Earliest Submission Date): December 6, 2019
Letter of Intent Due Date(s): Not applicable.
Application Due Date(s): Standard dates apply, by 5:00 PM local time of applicant organization.
URL for more information:

Filed Under: Funding Opportunities