Post-Acute Care Research and Team Science (PACRATS)
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:
- Emphasizing the role of community engagement,
- Standardizing study designs that adhere to regulatory requirements in our complex health care environment, and
- Developing research best practices for older, and often vulnerable, patient populations.
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.
Research Areas
Our researchers are currently working to improve post-acute and long-term care in the following areas:
- Improving communication to reduce medication errors and readmissions
- Preventing and improving outcomes surrounding hospital-acquired conditions, including catheter-associated urinary tract infections (CAUTI), falls, pressure ulcers, delirium
- Models of care: Acute Care of the Elderly (ACE) unit; ACE tracker
- Hospital deconditioning
- Improving rehabilitation in transition from hospital to home
- Design, development and evaluation of information technologies to improve clinician support and patient health outcomes in post-acute care settings: telehealth, remote monitoring and clinical decision support systems
- High-intensity rehabilitation with a multidisciplinary approach
- Improving care coordination and communication between clinicians in different settings for patients transitioning from the hospital to home health care
- Understanding factors related to hospital readmissions from HHC
- Better understanding patient and caregiver perspectives on needs during home health care transitions
- Improving heart failure disease management, including nursing education, program development and patient self-care
- Reducing unnecessary SNF utilization after total knee arthroplasty
- Prognostic data of low and high performing clusters of VA contracted SNFs and CLCs
- Qualitative analysis of decision-making for SNFs
- High-intensity rehabilitation to improve short and long-term outcomes following hospitalization
- Preventing and improving outcomes surrounding hospital-acquired conditions, including CAUTI, falls, pressure ulcers, delirium
- Stakeholder engagement in SNF and LTC
- Impact of insurance type on care
- Response to 5-star quality ratings, validity of ratings, consumer and provider view of ratings
- Hospice care in nursing homes
- Medical foster home as an alternative to nursing home costs, safety, Minimum Data Set assessments
- Advance care planning in home-based primary care and Veteran’s Administration (VA) nursing homes
- Home-based primary care optimizing organizational structure
- Prevention of healthcare-associated conditions including catheter-associated urinary tract infections (CAUTI), falls, pressure ulcers, delirium
- Antimicrobial stewardship
- Community engagement and analysis of decision-support tool
- Analyzing standardized falls assessment and physical function data at InnovAge to improve time to intervention and reduce unnecessary utilization
- Treatment effect of provider contact to reduce community-dwelling falls
Grant Support
| 2016-2021 | 5K08 HS024569 | 9 cal months (PI) |
| AHRQ | $150,864/year | |
| Improving Care Coordination Between Clinicians to Optimize Care Transitions to Home Health Care PI-Jones | ||
| 2018-2022 | R13 AG058386 -01 | 0 cal months (co-I) |
| NIA, NIH | $47,954/year | |
| 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) |
| NIA, NIH | $145,696 | |
| 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 VA HSR&D | 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 | ||
Publications
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, 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.
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.
Burke RE, Cumbler E, et al. Post-acute care reform: Implications and opportunities for hospitalists. J Hosp Med. 2017 Jan;12(1):46-51.
Burke RE, Jones CD, et al. Use of post-acute careafter hospital discharge in urban and rural hospitals. Am J Accountable Care.2017 Mar; 5(1):16-22.
Daddato A, Wald HL, et al. A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned. Clin Trials. 2017 Jun;14(3):308-313.
Falvey JR, Gustavson AM, et al. Dementia, Comorbidity, and Physical Function in the Program of All-Inclusive Care for the Elderly. J Geriatr Phys Ther. 2017.
Gustavson AM, Falvey JR, et al. Predictors of Functional Change in a Skilled Nursing Facility Population. J Geriatr PhysTher. 2017.
Horney C, Capp R, et al. Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities. J Am Geriatr Soc. 2017 Jun; 65(6):1199-1205.
Jones CD, Bowles KH, et al. High-Value Home Health Care for Patients with Heart Failure: An Opportunity to Optimize Transitions from Hospital to Home. Circ Cardiovasc Qual Outcomes. 2017;10(5).
Jones CD, Cumbler E, et al. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. J Am Med Dir Assoc. 2017 Jan; 18(1):70-73.
Jones CD, Wald HL, et al. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health Serv Res. 2017 04; 52(2):879-894.
Jones CD,Jones J, et al. “Connecting the dots”: a qualitative study of home health nurse perspectives on coordinating care for recently-discharged patients. J GenIntern Med. 2017.
Jones J, Lawrence E, et al. Nurses' Role in Managing "The Fit" of Older Adults in Skilled Nursing Facilities. J Gerontol Nurs. 2017 Dec 01; 43(12):11-20.
Jones W, Drake C, et al. Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design. Appl Clin Inform. 2017;8(2):632-650.
Laffon de Mazières C, Moreley JE, et al. Prevention of Functional Decline by Reframing the Role of NursingHomes? J Am Med Dir Assoc. 2017 Feb;18(2):105-110.
Leonard C, Lawrence E, et al. Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study. Implement Sci. 2017 Oct 23; 12(1):123.
Lum H, Obafemi O, et al. Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities. J Am Med Dir Assoc. 2017 Oct 1;18(10):885-890.
Perraillon MC, Brauner DJ, etal. Nursing Home Response to Nursing Home Compare: The Provider Perspective. Med Care Res Rev. 2017.
Trautner BW, Greene MT, et al. Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infect Control HospEpidemiol. 2017;38(1):83-88.
Burke RE, Jones CD, et al. Use of post-acute careafter hospital discharge in urban and rural hospitals. Am J Accountable Care.2017 Mar; 5(1):16-22.
Daddato A, Wald HL, et al. A randomized trial of heart failure disease management in skilled nursing facilities (SNF Connect): Lessons learned. Clin Trials. 2017 Jun;14(3):308-313.
Falvey JR, Gustavson AM, et al. Dementia, Comorbidity, and Physical Function in the Program of All-Inclusive Care for the Elderly. J Geriatr Phys Ther. 2017.
Gustavson AM, Falvey JR, et al. Predictors of Functional Change in a Skilled Nursing Facility Population. J Geriatr PhysTher. 2017.
Horney C, Capp R, et al. Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities. J Am Geriatr Soc. 2017 Jun; 65(6):1199-1205.
Jones CD, Bowles KH, et al. High-Value Home Health Care for Patients with Heart Failure: An Opportunity to Optimize Transitions from Hospital to Home. Circ Cardiovasc Qual Outcomes. 2017;10(5).
Jones CD, Cumbler E, et al. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. J Am Med Dir Assoc. 2017 Jan; 18(1):70-73.
Jones CD, Wald HL, et al. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health Serv Res. 2017 04; 52(2):879-894.
Jones CD,Jones J, et al. “Connecting the dots”: a qualitative study of home health nurse perspectives on coordinating care for recently-discharged patients. J GenIntern Med. 2017.
Jones J, Lawrence E, et al. Nurses' Role in Managing "The Fit" of Older Adults in Skilled Nursing Facilities. J Gerontol Nurs. 2017 Dec 01; 43(12):11-20.
Jones W, Drake C, et al. Developing Mobile Clinical Decision Support for Nursing Home Staff Assessment of Urinary Tract Infection using Goal-Directed Design. Appl Clin Inform. 2017;8(2):632-650.
Laffon de Mazières C, Moreley JE, et al. Prevention of Functional Decline by Reframing the Role of NursingHomes? J Am Med Dir Assoc. 2017 Feb;18(2):105-110.
Leonard C, Lawrence E, et al. Implementation and dissemination of a transition of care program for rural veterans: a controlled before and after study. Implement Sci. 2017 Oct 23; 12(1):123.
Lum H, Obafemi O, et al. Use of Medical Orders for Scope of Treatment for Heart Failure Patients During Postacute Care in Skilled Nursing Facilities. J Am Med Dir Assoc. 2017 Oct 1;18(10):885-890.
Perraillon MC, Brauner DJ, etal. Nursing Home Response to Nursing Home Compare: The Provider Perspective. Med Care Res Rev. 2017.
Trautner BW, Greene MT, et al. Infection Prevention and Antimicrobial Stewardship Knowledge for Selected Infections Among Nursing Home Personnel. Infect Control HospEpidemiol. 2017;38(1):83-88.
Burke RE, Whitfield EA, et al. Hospital Readmission From Post-Acute Care Facilities: Risk Factors, Timing, and Outcomes. J Am Med Dir Assoc. 2016 Mar 01; 17(3):249-55.
Dolansky MA, Capone L, et al. Targeting heart failure rehospitalizations in a skilled nursing facility: A case report. Heart Lung. 2016 Sep-Oct;45(5):392-6.
Falvey JR, Burke RE, etal. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016 08; 96(8):1125-34.
Gidwani R., Joyce N, et al. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. J Palliat Med. 2016;19(9):957-63.
Jones CD, Cumbler E, et al. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. J Am Med Dir Assoc. 2017 Jan;18(1):70-73.
Levy CR, Zargoush M, et al. Sequence of Functional Loss and Recovery in Nursing Homes. Gerontologist. 2016;56(1):52-61.
Lum HD, Jones J, et al. Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations. Ann Fam Med. 2016;14(2):125-32.
Manheim CE, Haverhals LM, et al. Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes. J Soc Work End Life Palliat Care. 2016;12(1-2):104-25.
Orr NM, Boxer RS, et al. Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?" J Card Fail. 2016 Dec;22(12):1004-1014.
Reeder B, Chung J, Stevens-Lapsley J. Current Telerehabilitation Research with Older Adults at Home: An Integrative Review. J Gerontol Nurs. 2016:42(10):15-20.
Sales AE, Ersek M, et al. Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol. Implement Sci.2016;11(1):132.
Stevens-Lapsley JE, Loyd BJ, et al. Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial. Clin Rehabil. 2016;30(8):776-85.
Zhu W, Luo L, Jain T, et al. DCDS: A Real-time Data Capture and Personalized Decision Support System for Heart Failure Patients in Skilled Nursing Facilities. AMIA Annu Symp Proc. 2017 Feb 10;2016:2100-2109.
Dolansky MA, Capone L, et al. Targeting heart failure rehospitalizations in a skilled nursing facility: A case report. Heart Lung. 2016 Sep-Oct;45(5):392-6.
Falvey JR, Burke RE, etal. Role of Physical Therapists in Reducing Hospital Readmissions: Optimizing Outcomes for Older Adults During Care Transitions From Hospital to Community. Phys Ther. 2016 08; 96(8):1125-34.
Gidwani R., Joyce N, et al. Gap between Recommendations and Practice of Palliative Care and Hospice in Cancer Patients. J Palliat Med. 2016;19(9):957-63.
Jones CD, Cumbler E, et al. Hospital to Post-Acute Care Facility Transfers: Identifying Targets for Information Exchange Quality Improvement. J Am Med Dir Assoc. 2017 Jan;18(1):70-73.
Levy CR, Zargoush M, et al. Sequence of Functional Loss and Recovery in Nursing Homes. Gerontologist. 2016;56(1):52-61.
Lum HD, Jones J, et al. Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations. Ann Fam Med. 2016;14(2):125-32.
Manheim CE, Haverhals LM, et al. Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes. J Soc Work End Life Palliat Care. 2016;12(1-2):104-25.
Orr NM, Boxer RS, et al. Skilled Nursing Facility Care for Patients With Heart Failure: Can We Make It "Heart Failure Ready?" J Card Fail. 2016 Dec;22(12):1004-1014.
Reeder B, Chung J, Stevens-Lapsley J. Current Telerehabilitation Research with Older Adults at Home: An Integrative Review. J Gerontol Nurs. 2016:42(10):15-20.
Sales AE, Ersek M, et al. Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol. Implement Sci.2016;11(1):132.
Stevens-Lapsley JE, Loyd BJ, et al. Progressive multi-component home-based physical therapy for deconditioned older adults following acute hospitalization: a pilot randomized controlled trial. Clin Rehabil. 2016;30(8):776-85.
Zhu W, Luo L, Jain T, et al. DCDS: A Real-time Data Capture and Personalized Decision Support System for Heart Failure Patients in Skilled Nursing Facilities. AMIA Annu Symp Proc. 2017 Feb 10;2016:2100-2109.
Anderson ME, Glasheen JJ, et al. Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis. Journal of Hospital Medicine. 2015;10(9):623–626.
Burke RE, Juarez-Colunga E, et al. Rise of post–acute care facilities as a discharge destination of us hospitalizations. JAMA Internal Medicine. 2015;175(2):295–296.
Burke RE, Juarez-Colunga E, et al. Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges from US Hospitals.Med Care. 2015;53(6);492-500.
Falvey JR, Burke RE, Stevens-Laplsey JE. Physical Function and Hospital Readmissions. JAMA Intern Med. 2015;175(10):1722.
Jones CD, Ginde AA, et al. Increasing home healthcare referrals upon discharge from US hospitals: 2001-2012. J Am Geriatr Soc. 2015;63(6):1265–1266.
Jurgens CY, Goodlin S, et al. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. J Card Fail. 2015 Apr;21(4):263-99.
Konetzka RT, Grabowski DC, et al. Nursing home 5-star rating system axacerbates disparities in quality, by payer source. Health Aff (Millwood).2015;34(5):819-27.
Konetzka RT, Grabowski DC, et al. The Role of Severe Dementia in Nursing Home Report Cards. Med Care Res Rev. 2015;72(5):562-79.
Lum HD, Jones J, et al. Unique challenges of hospice for patients with heart failure: A qualitative study of hospice clinicians. 2015;170(3):524-30.
Lum HD, Sudore RL, et al. Advance Care Planning in the Elderly. Med Clin North Am. 2015; 99(2):391-403.
Burke RE, Juarez-Colunga E, et al. Rise of post–acute care facilities as a discharge destination of us hospitalizations. JAMA Internal Medicine. 2015;175(2):295–296.
Burke RE, Juarez-Colunga E, et al. Patient and Hospitalization Characteristics Associated With Increased Postacute Care Facility Discharges from US Hospitals.Med Care. 2015;53(6);492-500.
Falvey JR, Burke RE, Stevens-Laplsey JE. Physical Function and Hospital Readmissions. JAMA Intern Med. 2015;175(10):1722.
Jones CD, Ginde AA, et al. Increasing home healthcare referrals upon discharge from US hospitals: 2001-2012. J Am Geriatr Soc. 2015;63(6):1265–1266.
Jurgens CY, Goodlin S, et al. Heart failure management in skilled nursing facilities: a scientific statement from the American Heart Association and the Heart Failure Society of America. J Card Fail. 2015 Apr;21(4):263-99.
Konetzka RT, Grabowski DC, et al. Nursing home 5-star rating system axacerbates disparities in quality, by payer source. Health Aff (Millwood).2015;34(5):819-27.
Konetzka RT, Grabowski DC, et al. The Role of Severe Dementia in Nursing Home Report Cards. Med Care Res Rev. 2015;72(5):562-79.
Lum HD, Jones J, et al. Unique challenges of hospice for patients with heart failure: A qualitative study of hospice clinicians. 2015;170(3):524-30.
Lum HD, Sudore RL, et al. Advance Care Planning in the Elderly. Med Clin North Am. 2015; 99(2):391-403.
Dolansky MA, Hitch JA, Piña IL, Boxer RS. Improving heart failure disease management in skilled nursing facilities: lessons learned. Clin Nurs Res. 2013 Nov;22(4):432-47.
Ozkaynak M, Brennan PF, et al. Patient-centered care requires a patient-oriented workflow model. J Am Med Inform Assoc. 2013.
Reeder B, Meyer E, et al. Framing the evidence for health smart homes and home-based consumer health technologies as a public health intervention for independent aging: a systematic review. Int J Med Inform. 2013;82(7):565-79.
Boxer RS, Dolansky MA, et al. The Bridge Project: improving heart failure care in skilled nursing facilities. J Am Med Dir Assoc. 2012 Jan;13(1):83.e1-7.
Misky GJ, Wald JL, et al. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-7.
Radcliff TA, Levy CR. Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents. J Hosp Med. 2010;5(2):E3-E10.
Ozkaynak M, Brennan PF, et al. Patient-centered care requires a patient-oriented workflow model. J Am Med Inform Assoc. 2013.
Reeder B, Meyer E, et al. Framing the evidence for health smart homes and home-based consumer health technologies as a public health intervention for independent aging: a systematic review. Int J Med Inform. 2013;82(7):565-79.
Boxer RS, Dolansky MA, et al. The Bridge Project: improving heart failure care in skilled nursing facilities. J Am Med Dir Assoc. 2012 Jan;13(1):83.e1-7.
Misky GJ, Wald JL, et al. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-7.
Radcliff TA, Levy CR. Examining guideline-concordant care for acute myocardial infarction (AMI): the case of hospitalized post-acute and long-term care (PAC/LTC) residents. J Hosp Med. 2010;5(2):E3-E10.
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