Projects

Vertical Integration for Patients with SMI (VIP-SMI)

This patient-centered transitions in care study is funded by the University of Rochester Medical Faculty Group and the University of Rochester Quality Institute’s innovation grant award.

The intervention includes a point-of care iPad-based prioritization tool to help patients identify and communicate their health-related priorities prior to discharge (Project 1), and expands the reach of an existing Transitional Care Management (TCM) program via systematization of the work of “comprehensivist clinicians” who provide a bridge between the hospitalist and primary care teams (Project 2). 

Intervention activities include individualized pre-discharge and post-discharge processes aimed at supporting and engaging patients in transitions back to the community. 

Post-hospitalization Improvements in Transition (PHIT)

Clinical and research leaders are working collaboratively to develop and evaluate an intensive, patient-centered approach to transitioning patient care from the hospital to the community. The project will focus on integrating proactive psychological services into the daily work-flow of a medical unit. 

Primary goals will be to assess the effectiveness of a program aimed at:

1. Expedited triage of mental health assessments including suicide risk

2. Development of a patient-centered discharge transition program