PACRATS is a multidisciplinary group of investigators at the University of Colorado. Our goal is to improve the approach researchers take within the post-acute care community by:
Our group includes researchers from the School of Medicine, the Division of Health Care Policy and Research, the Department of Medicine, College of Nursing, the PACE program and community providers. Pre-and post-doctoral trainees are also involved.
During our monthly meetings, we collaborate with community-based providers and members of the post-acute care community to discuss ways of improving care.
|2016-2021||5K08 HS024569||9 cal months (PI)|
|Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care|
|2018-2022||R13 AG058386 -01||0 cal months (co-I)|
|A Conference for Patient Centered Post-Acute Care|
|2020-2022||R21 AG067038||2.4 cal months (PI)|
|National Institute on Aging||$150,000 yr 1, $125,000 yr 2|
|Development and Evaluation of a Palliative-Transitional Home Health Care Model|
The overarching goal of this R21 proposal is to engage key stakeholders including hospitalists, primary care providers, home health clinicians (e.g., nurses, physical therapists, social workers), patients, and informal caregivers, to develop, refine, and pilot test a Palliative-Transitional Home Health Care (PT HHC) model to provide enhanced support after discharge for patients at high mortality risk.
|2020-2025||QUERI 20-013||3 cal months (co-I)|
|VA Quality Enhancement Research Initiative||$1,020,000|
|Value-Based Care to Improve the Quadruple Aim for Veterans and Stakeholders QUERI|
This study evaluates implementation of three evidence-based practices for to improve care coordination for: 1) Veterans who receive inpatient care in community hospitals, Veterans referred for home health after hospital discharge, and Veterans referred to community providers for medication-assisted treatment for substance use disorders.
|2018-2021||R13 AG058386-01||1.2 cal months (PI)|
|A Conference for Patient Centered Post-Acute Care|
|2016-2020||I01 RX-001978||0.6 cal months (co-I)|
|VA Merit Award RR&D||$ 1,098,679|
|Improving Function in Older Veterans with Hospital-associated Deconditioning|
|2015-2020|| QUERI 15-288|
|3 cal months (Project PI for Home Based Primary Care Setting of Care)|
|$436,333 Project Budget $3,982,173 Total Program Budget|
|Implementing Goals of Care Conversations with Veterans in VA LTC Settings|
Ayele R, Manges KA, Leonard C, Molla M, Levy C, Burke R. How Context Influences Hospital Readmissions from Skilled Nursing Facilities: A Rapid Ethnographic Study. J Am Med Dir Assn Sept 14, 2020. https://doi.org/10.1016/j.jamda.2020.08.001 PMID: 32943342
Falvey JR, Bade MJ, Hogan C, Forster JE, Stevens-Lapsley JE. Preoperative activities of daily living dependency is associated with higher 30-day readmission risk for older adults after total joint arthroplasty. Clin Orthop Relat Res. 2020 Feb;478(2):231-237. doi: 10.1097/CORR.0000000000001040. PubMed PMID: 31688209; NIHMSID:NIHMS1548964.
Falvey JR, Murphy TE, Gill TM, Stevens-Lapsley JE, Ferrante LE. Home health rehabilitation utilization among Medicare beneficiaries following critical illness. J Am Geriatr Soc. 2020 Jul;68(7):1512-1519. doi: 10.1111/jgs.16412. Epub 2020 Mar 18. PubMed PMID: 32187664.
Gillespie SM, Li J, Karuza J, Levy C, Dang ,Olsan T, Kinosian B, Intrator I. Factors Associated with Hospitalization by Veterans in Home Based Primary Care. J Am Med Dir Assoc, in press.
Gustavson AM, Forster JE, LeDoux CV, Stevens-Lapsley JE. Multi-participant rehabilitation in skilled nursing facilities: an observational comparison study (2020). J Am Med Dir Assoc. 2020 Jul 6;. doi: 10.1016/j.jamda.2020.05.002. [Epub ahead of print] PubMed PMID: 32646824.
Gustavson AM, LeDoux CV, Stutzbach JA, Miller MJ, Seidler KJ, Stevens-Lapsley JE. Mixed methods approach to understanding determinants of practice change in skilled nursing facility rehabilitation: adaptation and sustaining value with post-acute reform. Accepted for publication 2020. Journal of Geriatric Physical Therapy.
Gustavson AM, Malone DJ, Boxer RS, Forster JE, Stevens-Lapsley JE. Application of High-Intensity Functional Resistance Training in a Skilled Nursing Facility: An Implementation Study. Phys Ther. 2020 Sep 28;100(10):1746-1758. doi: 10.1093/ptj/pzaa126. PubMed PMID: 32750132; PubMed Central PMCID: PMC7530575.
Intrator O, Li J, Gillespie SM, Levy C, Davis D, Edes T, Kinosian B, Karuza J. Benchmarking Site of Death and Hospice Use: A Case Study of Veterans Cared by Department of Veterans Affairs Home-based Primary Care. Med Care. 2020 Sep; 58(9):805-814. doi: 10.1097/MLR.0000000000001361. PubMed PMID: 32826746.
Jones CD, Nearing KA, Burke RE, Lum HD, Boxer RS, Stevens-Lapsley JE, Ozkaynak M, Levy CR. "What Would It Take to Transform Post-Acute Care?" 2019 Conference Proceedings on Re-envisioning Post-Acute Care. J Am Med Dir Assoc. 2020 Aug;21(8):1012-1014. doi: 10.1016/j.jamda.2020.02.004. Epub 2020 Mar 17. PubMed PMID: 32192872; PubMed Central PMCID: PMC7396295.
Landis-Lewis Z, Kononowech J, Scott WJ, Hogikyan RV, Carpenter JG, Periyakoil VS, Miller SC, Levy C, Ersek M, Sales A. Designing Clinical Practice Feedback Reports: Three Steps Illustrated in Veterans Health Affairs Ling-Term Care Facilities and Programs. Implementation Sci. 2020 Jan 21; 15(1):7. doi: 10.1186/s13012-019-0950-y PMID: 31964414
LeDoux CV, Lindrooth RC, Seidler KJ, Falvey JR, Stevens-Lapsley JE. The impact of home health physical therapy on Medicare beneficiaries with a primary diagnosis of dementia. J Am Geriatr Soc. 2020 Apr;68(4):867-871. doi: 10.1111/jgs.16307. Epub 2020 Jan 13. PubMed PMID: 31930736.
Levy C, Ersek M, Scott W, Carpenter JG, Kononowech J, Phibbs C, Lowry J, Cohen J, Foglia M. Life-Sustaining Treatment Decisions Initiative: Early Implementation Results of a National Veterans Affairs Program to Honor Veterans’ Care Preferences. J Gen Intern Med. 2020 Feb. doi: 10.1007/s11606-020-05697-2 PMID: 32096084
Lum HD, Sukes J, Daddato AE, Juarez-Colunga E, Shanbhag P, Kutner J, Levy CR, Sudore RL. Effectiveness of Advance Care Planning Group Visits Among Older Adults in Primary Care. American Geriatrics Society. July 2020. https://doi.org/10.1111/jgs.16694
Manheim, C., Haverhals, L.M., Gilman, C., Karuza, J., Olsan, T., Edwards, S., Levy, C. & Gillespie, S. VA Home Based Primary Care Teams: Partnering and Acting as Caregivers for Veterans. Submitted to Home Health Care Services Quarterly
Miller SC, Scott WJ, Ersek M, Levy C, Hogikyan R, Periyakoil VS, Carpenter JG, Cohen J, Foglia MB. Honoring Veterans' Preferences: The Association between Comfort Care Goals and Care Received at the End of Life. J Pain Symptom Management. 2020 Sep 7; doi: 10.1016/j.jpainsymman.2020.08.039. [Epub ahead of print] PubMed PMID: 32911038.
Presley CJ, Han L, O’Leary JR, Zhu W, Corneau E, Chao H, Shamas T, Rose M, Lorenz K, Levy CR, Mor V, Gross CP. Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran’s Health Administration. J Palliat Med. 2020 Mar 2. PMID: 32119800
Sterling MR, Kern LM, Safford MM, Jones CD, Feldman PH, Fonarow GC, Sheng S, Matsouaka RA, DeVore AD, Lytle B, Xu H, Allen LA, Deswal A, Yancy CW, Albert NM. Home Health Care Use and Post-Discharge Outcomes after Heart Failure Hospitalizations. JACC Heart Failure. 2020 Dec;8(12):1038-1049. doi: 10.1016/j.jchf.2020.06.009. Epub 2020 Aug 12.
Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-Traumatic Stress Disorder to End-of-Life Care Received by Dying Veterans: A Secondary Data Analysis. J Gen Intern Med. Dec 2019. Epub ahead of print doi 10.1007/s11606-019-05538-x
Callister C, Jones J, Schroeder S, Breathett K, Dollar B, Sanghvi UJ, Harnke B, Lum H, Jones CD. Caregiver Experiences of Care Coordination for Recently Discharged Patients: A Qualitative Metasynthesis. Western Journal of Nursing Research 2020 Aug;42(8):649-659. doi: 10.1177/0193945919880183. Epub 2019 Oct 4.
Carpenter, J., Miller, S., Kolanowski, A., Karel, M., Periyakoil, V., Lowery, J., Levy, C., Sales, A., Ersek., M. Partnership to Enhance Resident Outcomes for Community Living Center (CLC) Residents with Dementia: Description of the Protocol and Preliminary Findings. J Gerontol Nurs. 2019. 45(3), 21-30. PMID: 30789986.
Falvey JR, Burke RE, Levy CR, Gustavson AM, Price L, Forster JE, Stevens-Lapsley JE. Impaired physical performance predicts hospitalization risk for participants in the program of all-inclusive care for the elderly. Phys Ther. 2019 Jan 1;99(1):28-36. doi: 10.1093/ptj/pzy127.
Falvey JR, Burke RE, Ridgeway KJ, Malone DJ, Forster JE, Stevens-Lapsley JE. Involvement of acute care physical therapists in care transitions for older adults following acute hospitalization: A cross-sectional national survey [published online ahead of print March 12, 2018]. J Geriatr Phys Ther. 2019 Jul/Sep;42(3):E73-E80. doi: 10.1519/JPT.0000000000000187.
Falvey JR, Gustavson AM, Price L, Papazian L, Stevens-Lapsley JE. Dementia, comorbidity, and physical function in the program of all-inclusive care for the elderly. J Geriatr Phys Ther. 2019 Apr/Jun;42(2):E1-E6. doi: 10.1519/JPT.0000000000000131.
Falvey JR, Mangione KK, Nordon-Craft A, Cumbler E, Burrows KL, Forster JE, Stevens-Lapsley JE. Progressive multicomponent intervention for older adults in home health settings following acute hospitalization: randomized clinical trial protocol. Phys Ther. 2019 Sep 1;99(9):1141-1149. doi: 10.1093/ptj/pzz069.
Gillespie S, Manheim C, Gilman C, Karuza J, Olsan T, Edwards S, Levy C, Haverhals L. Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study. American Journal of Geriatric Psychiatry. Feb 2019; 27:128-137.
Gustavson AM, Drake C, Lakin A, Daddato AE, Falvey JR, Capell W, Lum HD, Jones CD, Unroe KT, Towsley GL, Stevens-Lapsley JE, Levy CR, Boxer RS. Conducting clinical research in post-acute and long-term nursing home care settings: Regulatory challenges [published online ahead of print April 21, 2017]. J Am Med Dir Assoc. 2019 Jul;20(7):798-803. doi: 10.1016/j.jamda.2019.04.022.
Gustavson AM, Falvey JR, Forster JE, Stevens-Lapsley JE. Predictors of functional change in a skilled nursing facility population. J Geriatr Phys Ther. 2019 Jul/Sep;42(3):189-195. doi: 10.1519/JPT.0000000000000137.
Haverhals L, Manheim C, Gilman C, Karuza J, Olsan T, Edwards ST, Levy C, Gillespie S. Dedicated to the Mission: Strategies VA Home-Based Primary Care Teams Apply to Keep Veterans at Home. Journal of the American Geriatrics Society. Oct 2019. doi: 10.1111/jgs.16171 PMID: 31593296.
Jones CD, Boxer RS. Home Care After Elective Vascular Surgery - Still More Questions than Answers. BMJ Quality & Safety. 2019 Dec 3. Pii:bmjqs-2019-009754. doi: 10.1136/bmjqs-2019-009754. [Epub ahead of print]
Jones CD, Falvey J, Hess E, Levy CR, Nuccio E, Barón AE, Masoudi FA, Stevens-Lapsley J. Predicting hospital readmissions from home healthcare in Medicare beneficiaries. J Am Geriatr Soc. 2019 Dec;67(12):2505-2510. doi: 10.1111/jgs.16153. Epub 2019 Aug 29. PubMed PMID: 31463941; PubMed Central PMCID: PMC7323864.
Jones CD, Jones J, Bowles KH, Flynn L, Masoudi FA, Coleman EA, Levy C, Wald HL, Boxer RS. Quality of Hospital Communication and Patient Preparation for Home Health Care: Results from a statewide survey of home health care nurses and staff. J Am Med Dir Assoc. 2019 Feb 18. pii: S1525-8610(19)30006-4. doi: 10.1016/j.jamda.2019.01.004. [Epub ahead of print]
Jones CD, Jones J, Bowles KH, Schroeder S, Masoudi FA, Coleman EA, Falvey J, Levy CR, Boxer RS. Patient, Caregiver, and Clinician Perspectives on Expectations for Home Health Care after Discharge: A Qualitative Case Study. J Hosp Med. 2019 Feb;14(2):90-95. doi: 10.12788/jhm.3140.
Miller MJ, Cook PF, Kline PW, Anderson CB, Stevens-Lapsley JE, Christiansen CL. Physical function and pre-amputation characteristics explain daily step count after dysvascular amputation. PM R. 2019 Oct;11(10):1050-1058. doi: 10.1002/pmrj.12121. Epub 2019 Apr 17. PubMed PMID: 30729727.
Mor V, Wagner TH, Levy C, Ersek M, Miller S, Gidwani-Marszowski R, Joyce N, Faricy-Anderson K, Corneau EA, Lorenz K, Kinosian B and Shreve S. Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer. JAMA Oncology. 2019 Jun 1;5(6):810-816. doi: 10.1001/jamaoncol.2019.0081. PMID: 30920603
Wallace MA, Hammes A, Rothman MS, Trizno AA, Jones CD, Cumbler E, McDevitt K, Carlson ND, Stoneback JW. Fixing a Fragmented System: Impact of a Comprehensive Geriatric Hip Fracture Program on Long-Term Mortality. Kaiser Permanente Journal. 2019;23. doi: 10.7812/TPP/18.286. Epub 2019 Nov 1.
Burke RE, Greysen SR. Reducing SNF Readmissions: At What Cost? J Hosp Med. 2018 Apr; 13(4):285-286.
Burke RE, Hess E, et al.Predicting Potential Adverse Events During a Skilled Nursing Facility Stay: A Skilled Nursing Facility Prognosis Score. J Am Geriatr Soc. 2018 May;66(5):930-936.
Burke RE, Ibrahim SA. Discharge Destination and Disparities in Postoperative Care. JAMA. 2018 Apr 24; 319(16):1653-1654.
Burke RE, Jones CD, et al. Infuence of Nonindex Hospital Readmission on Length of Stay and Mortality. MedCare. 2018 Jan; 56(1):85-90.
Burke RE, Jones J, et al. Evaluating the Quality of Patient Decision-Making Regarding Post-Acute Care. J Gen Intern Med. 2018 May; 33(5):678-684.
Falvey JR, Burke RE, et al. Involvement of Acute Care Physical Therapists in Care Transitions for Older Adults Following Acute Hospitalization: A Cross-sectional National Survey. J Geriatr Phys Ther. 2018;12.
Gustavson A, Boxer R, et al. Advancing Innovation in Skilled Nursing Facilities through Academic Collaborations. PTJ-PAL. 2018 Aug; 18(3): 5-16.
Jones CD, and Burke RE. “Inpatient Notes: Getting Past the “Black Box" - Opportunities for Hospitalists to Improve Postacute Care Transitions.” Ann Intern Med. 2018;168(10):HO2-HO3.
Ozkayanak M, Reeder B, et al. Characterizing Workflow to Inform Clinical Decision Support Systems in Nursing Homes. Gerontologist. 2018.