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Homecare-CONCERN: Building risk models for preventable hospitalizations and emergency department visits in homecare

Award Number: R01HS027742
ORGANIZATION: AGENCY FOR HEALTH CARE RESEARCH AND QUALITY
OPDIV: AHRQ
AWARD CLASS: DISCRETIONARY
AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)
PERIOD OF PERFORMANCE START DATE: 09/30/2020
PERIOD OF PERFORMANCE END DATE: 07/31/2025

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Homecare-CONCERN: Building risk models for preventable hospitalizations and emergency department visits in homecare - Project Summary/Abstract Every year, more than 11,000 homecare agencies across the United States provide care to more than 5 million older adults. Currently, about one in three homecare patients are hospitalized or visit an emergency department (ED) during the 30-60 day homecare episode. Up to 40% of these events are preventable with appropriate and timely care. In our pilot work, we developed a risk prediction model (called Homecare- CONCERN) that accurately identified patients at risk for hospital admission and ED visits solely from homecare clinical notes using NLP. This study brings together an interdisciplinary team of experts in homecare, data science, nursing and risk model development to explore whether cutting-edge data science approaches can improve timely identification of patients at risk in homecare. Our specific aims are to: 1. Further develop and validate a preventable hospitalization or ED visit risk prediction model (Homecare- CONCERN). We will apply traditional (time varying Cox regression) and cutting-edge time-sensitive analytical methods (Deep Survival Analysis and Long-Short Term Memory Neural Network) for risk model development. 2. Prepare Homecare-CONCERN for clinical trial via pilot testing. We will apply user centered design to develop Homecare-CONCERN clinical decision support tool and pilot test the tool for clinical validity and acceptability. 3. Inform the future implementation of Homecare-CONCERN clinical decision support tool in the homecare setting. We will examine if all risk elements can be mapped to a data standard (Fast Healthcare Interoperability Resources - FHIR) and conduct interviews with key informants across the US about current readiness, barriers and facilitators, and implementation strategies for adopting such tools in homecare setting. This proposal addresses the AHRQ program announcement (PA-18-795) to harness data to improve healthcare quality and patient outcomes. The study will build a first-of-a-kind clinical decision support system to trigger timely and personalized alerts about concerning patient trends that activate appropriate and timely care to prevent avoidable hospitalizations and ED visits from homecare.


Issue Date FY	Funding FY	Legal Entity Name	Legal Entity Address	Legal Entity City	Legal Entity State	Legal Entity Zip Code	Legal Entity COUNTY	Legal Entity COUNTRY	Assistance Listing	Award Code	Budget Year	Action Date	Action Type	Action Amount

Issue Date FY: 2024 ( Subtotal = $0 )
2024	2023	VISITING NURSE SERVICE OF NEW YORK	220 E 42ND ST FL 6	NEW YORK	NY	10017	NEW YORK	USA	Research on Healthcare Costs, Quality and Outcomes	000	4	6/25/2024	NON-COMPETING CONTINUATION	$0
														Subtotal = $0

Issue Date FY: 2023 ( Subtotal = $382,317 )
2023	2023	VISITING NURSE SERVICE OF NEW YORK	220 E 42ND ST FL 6	NEW YORK	NY	10017	NEW YORK	USA	Research on Healthcare Costs, Quality and Outcomes	000	4	6/30/2023	NON-COMPETING CONTINUATION	$382,317
														Subtotal = $382,317

Issue Date FY: 2022 ( Subtotal = $367,985 )
2022	2022	VISITING NURSE SERVICE OF NEW YORK	220 E 42ND ST FL 6	NEW YORK	NY	10017	NEW YORK	USA	Research on Healthcare Costs, Quality and Outcomes	000	3	7/13/2022	NON-COMPETING CONTINUATION	$367,985
														Subtotal = $367,985

Issue Date FY: 2021 ( Subtotal = $369,427 )
2021	2021	VISITING NURSE SERVICE OF NEW YORK	220 E 42ND ST FL 6	NEW YORK	NY	10017	NEW YORK	USA	Research on Healthcare Costs, Quality and Outcomes	000	2	6/29/2021	NON-COMPETING CONTINUATION	$369,427
														Subtotal = $369,427

Issue Date FY: 2020 ( Subtotal = $400,000 )
2020	2020	VISITING NURSE SERVICE OF NEW YORK	220 E 42ND ST FL 6	NEW YORK	NY	10017	NEW YORK	USA	Research on Healthcare Costs, Quality and Outcomes	000	1	9/16/2020	NEW	$400,000
														Subtotal = $400,000

Grand Total All Awards = $1,519,729

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Homecare-CONCERN: Building risk models for preventable hospitalizations and emergency department visits in homecare

Award Number: R01HS027742

ORGANIZATION: AGENCY FOR HEALTH CARE RESEARCH AND QUALITY

OPDIV: AHRQ

AWARD CLASS: DISCRETIONARY

AWARD ACTIVITY TYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)

PERIOD OF PERFORMANCE START DATE: 09/30/2020

PERIOD OF PERFORMANCE END DATE: 07/31/2025

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