Evidence Bank

The Evidence Bank is a collection of research studies on common services provided by CBOs that demonstrate outcomes attractive to a health care partner. This collection is updated on a monthly basis. For more information, read our Explanations and Instructions page.

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Care Transitions September 25, 2006 Care Transitions Program Background Patients with complex care needs who require care across different health care settings are vulnerable to experiencing serious quality problems. A care transitions intervention designed to encourage patients and their caregivers to assert a more active role during care trans... Read More
Care Transitions November 14, 2018 The Bridge Model for Super Utilizers The present study was a retrospective evaluation of a social worker-led transitional care intervention that addresses the medical and social needs of inpatient super utilizers with ≥5 inpatient admissions in a 12-month period. Bivariate analyses revealed significant reductions in the to... Read More
Care Transitions April 27, 2016 The Bridge Model Summary  Efforts to reduce readmissions after hospital discharge are increasingly being made to better identify and address social and logistical needs in addition to attending to post-hospital clinical challenges. A transitional care model based in the social work professional skill s... Read More
Care Transitions November 1, 2018 Community Passport to Care (ComPass 2c) Purpose To evaluate the ComPass2c program by (1) effectiveness in reducing 30-day hospital readmissions, (2) reach of program into target population, and (3) implementation of key program elements. Primary Practice Setting  An academic hospital in New England (John Dempsey Hospital).... Read More
Care Transitions June 27, 2014 Transitional Care Model Aim The goal of this study was to compare post-acute care costs of three care management interventions. Materials & Methods  A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Mo... Read More
Care Transitions March 4, 2014 Care Transitions Program Background Poorly-executed transitions out of the hospital contribute significant costs to the healthcare system. Several evidence-based interventions can reduce post-discharge utilization. Objective To evaluate the cost avoidance associated with implementation of the Care Transition... Read More
Care Transitions October 26, 2004 Care Transitions Program Objectives To test whether an intervention designed to encourage older patients and their caregivers to assert a more active role during care transitions can reduce re-hospitalization rates. Design Quasi-experimental design whereby subjects receiving the intervention (n=158) were com... Read More
Care Transitions June 13, 2014 Transitions in Care Program ABSTRACT Conducted between July 2011 through September 2013 at Barnabas Health in Northern New Jersey. All patients age 65 and older who came into medical center’s emergency department or were admitted to the hospital were screened for dementia, frailty, and chronic conditions. Staff e... Read More
Care Management/Care Coordination April 25, 2016 The Ambulatory Integration of the Medical and Social Model Abstract  An exploratory, retrospective evaluation of Ambulatory Integration of the Medical and Social (AIMS), a care coordination model designed to integrate medical and non-medical needs of patients and delivered exclusively by social workers was conducted to examine mean utilization... Read More
Care Management/Care Coordination, Interdisciplinary Team Care March 14, 2011 Guided Care Background The effect of interdisciplinary primary care teams on the use of health services by patients with multiple chronic conditions is uncertain. This study aimed to measure the effect of guided care teams on multi-morbid older patients\' use of health services. Methods Eligible... Read More
Care Management/Care Coordination April 1, 2014 The Individualized Management for Patient-Centered Targets (IMPaCT) Importance  Socioeconomic and behavioral factors can negatively influence post-hospital outcomes among patients of low socioeconomic status (SES). Traditional hospital personnel often lack the time, skills, and community linkages required to address these factors. Objective To determ... Read More
Care Management/Care Coordination November 2, 2018 The Johns Hopkins Community Health Partnership (J-CHiP) Importance  The Johns Hopkins Community Health Partnership was created to improve care coordination across the continuum in East Baltimore, Maryland. Objective To determine whether the Johns Hopkins Community Health Partnership (J-CHiP) was associated with improved outcomes and lower... Read More
Mental Health December 17, 2014 Beat the Blues Objectives To test the cost-effectiveness of a home-based depression program, Beat the Blues (BTB). Design We conducted a cost-effectiveness analysis as part of a previously reported randomized controlled trial that tested BTB versus a wait-list control group. Setting Community-dwe... Read More