Improving Post-Discharge Care for Surgical Patients: The Challenge of Cross--Organizational Coordination


Coordinating an individual patient's care can be a daunting challenge. Not only may a patient's providers span multiple institutions, but they may change over time as patients move from acute to rehabilitative to home care. Poor coordination among providers affects both the quality and efficiency of patient care. This project will test an intervention designed to improve coordination across the care continuum by creating a coordinated care team. The team will include all the providers caring for a patient undergoing knee or hip replacement surgery during a one-year period. Participating providers will agree on a plan to communicate and exchange information about the progress of their patient. At the end of the intervention, project staff will measure the impact on the patient's functional status, his or her satisfaction with care, and the quality of provider coordination. If proven effective, this team-based intervention could, at a relatively low cost, improve care coordination and, in turn, patients' outcomes and satisfaction with the care system.

Grant Details

Grantee Organization:
Brandeis University
Principal Investigator:
Jody Hoffer Gittell, Ph.D.
Award Amount:
Approval Date:
November 13, 2001

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