Research Priorities

• Enhancing quality of care in private duty home care services (i. Develop a process to assess for “risk” of unplanned hospitalizations or falls; ii. Create a risk score and intervention strategy that will lead to early intervention to reduce hospital admission and/or falls)
• Assessing the impact of payment models (PDGM, case rates, FFS, HHVBP) on clinical and financial outcomes (ACH, patient satisfaction, visit utilization, revenue per visit, etc)
• Examining the effect rehabilitation and/or nursing dosage (frequency, time and episode length) on outcomes (clinical and financial) (i. What is the right amount of care by the right provider(s) that results in the best outcomes?)

• Assess disparities in access, quality, and outcomes of rehabilitation
• Study ambulatory scheduling practices across all patients/payers, determine efficiency opportunities to provide care for patients within our ACO/system; Study the impacts and characterized predictors of adherence to therapeutic plan of care design to the patient outcome in the outpatient setting.
• Development of Team-based models of care, care coordination improvement for patients, determine outcome change.

• Reducing disability and poor clinical outcomes among elderly patients by early mobilization in the emergency department, inpatient and critical care areas and avoiding the need for prolonged post-acute care.
• Early identification and reduction in the risk of delirium among vulnerable adults to reduce the risk of cognitive decline, prolonged hospitalization, and need for long-term care.
• Expanding the role of patient and family engagement in reducing iatrogenic injury and diagnostic delay among vulnerable patients with functional limitations.
• Using information technology to identify and prevent clinical deterioration in ambulatory patients with chronic conditions.

Please note that this health system will not be hosting a LHS Scientist in 2025

• Standardize cognitive assessment in the acute care hospital

• Addressing social determinants of health within a PACE population
• Fall reduction
• End-of-life and advance care planning
• Medication safety and deprescribing
• Vaccinations and infection prevention
• Improving participant/patient engagement
• ER diversion/avoidance

Please note that this health system will not be hosting a LHS Scientist in 2025

• Transitions of care across the continuum
• Value-based care pathways
• Effectiveness of rehabilitation for high-need / high-cost patients
• Team-based models of care, care coordination

• Implementation of systematic approaches to improve mobility of patients in the acute care setting, particularly those at high risk (e.g., individuals’ chronic conditions such as CHF)
• Precision Rehabilitation: Using high information content measurement to personalize rehabilitation interventions across the healthcare continuum for individuals with disability and/or chronic conditions
• Effectiveness of innovative care delivery models prior to surgery especially for geriatric populations with multiple chronic conditions
• Development of rehabilitation models of care to reduce skilled nursing facility utilization

• Complex care management and outcomes in individuals with serious illness
• Access to sustainable adaptive sport programs for people with disabilities
• Improving post-acute transitional care

• Evaluation of downstream impact throughout the health system for specialty assistive technology and durable medical equipment services.
• Effectiveness of uniform communication pathways for care transition in individuals with disabilities (inpatient to outpatient and/or pediatrics to adulthood).
• Development, implementation, and evaluation of assistive technology and durable medical equipment through patient reported outcomes.

• Clinical outcomes of the hybrid telehealth model
• Physical therapy dosage and its effect on length of stay (LOS)