Priority topics:

• Implementation of a mobility program in post-acute care
• Transitions of care across the continuum
• Telehealth during the coronavirus pandemic
• Safety during the coronavirus pandemic
• Workforce issues during the coronavirus pandemic
• Feasibility of MDS Section GG scores to predict discharge location
• Improving efficiency in obtaining functional change outcomes

Priority topics:

• Patient-Driven care plan design and the resulting impact on quality outcomes
• Variation in quality outcomes related to different payment models
• Unintended consequences of the coronavirus pandemic
• Policy changes during the coronavirus pandemic
• Policy and payment changes in the home health setting

BAYADA is particularly interested in focusing on the first priority, assessing the quality/effectiveness of patient-driven care plans. In late 2019, in response to CMS’s shift to the Patient-Driven Groupings Model (PDGM) for home health payment and the coronavirus pandemic, BAYADA implemented a new care planning process for home health patients. This process utilizes structured team conversations at specified time points after the initiation of care for each patient.  BAYADA would like to investigate the impact of this new care planning process on an array of clinical and functional quality outcomes, in comparison to historical performance (i.e., pre- post- design) and/or a control group of patients who did not receive this care planning due to insurance/payer-related restrictions.

Priority topics:

• Implementation of a mobility program in acute care
• Transitions of care across the continuum
  
• Telehealth during the coronavirus pandemic
  
• Team-based models of care, care coordination
  
• Disparities in access, quality, and outcomes of rehabilitation

BMC is particularly interested in addressing the problem of overuse and inappropriate use of acute care therapists; integrating the use of AMPAC mobility and activity measures in their outpatient settings; and effective capture and utilization of outcomes data in the EHR and in the context of their diverse patient population.

Priority topics:

• Implementation of a mobility program in acute care
  
• Transitions of care across the continuum
  
• Effectiveness of pre-habilitation in surgical care
  
• Unintended consequences of the coronavirus pandemic
  
• Disparities in access, quality, and outcomes of rehabilitation

The Cleveland Clinic is particularly interested in improving transitions of care from the acute hospital to home health care setting.

View our current LeaRRn Scholar.

Priority topics:

• Implementation of a mobility program in acute care
• Transitions of care across the continuum
• Effectiveness of rehabilitation for high-need / high-cost patients
• Team-based models of care, care coordination
• Telehealth during and after the coronavirus pandemic

Intermountain Healthcare is particularly interested in team-based care and care coordination in the context of care transitions and the expansion of telehealth services.

View our current LeaRRn Scholar.

Priority topics:

• Implementation of a mobility program in acute care
  
• Transitions of care across the continuum
  
• Effectiveness of pre-habilitation in surgical care
  
• Unintended consequences of the coronavirus pandemic
  
• Team-based models of care, care coordination

Priority topics:

• Patient-Driven Payment Models
  
• Transitions of care across the continuum
  
• Effectiveness of rehabilitation for high-need / high-cost patients
  
• Team-based models of care, care coordination
  
• Unintended consequences of the coronavirus pandemic

Priority topics:

• Implementation of a mobility program in acute care
• Transitions of care across the continuum
  
• Effectiveness of rehabilitation for high-need / high-cost patients
  
• Effectiveness of pre-habilitation in surgical care
  
• Telehealth during the coronavirus pandemic

View our first LeaRRn Scholar.

View our second LeaRRn Scholar.

UPMC’s Innovative Homecare Solutions (UIHS)

Priority topics:

• Efficient use of rehabilitation services in the home health setting
• Use of technology in the home health setting to augment or as a substitute for nurse and/or therapist care