Patient-Centered Approaches to Transitional Care Research and Implementation: Overview and Insights From Patient-Centered Outcomes Research Institute's Transitional Care Portfolio.

Background: This Special Issue, Future Directions in Transitional Care Research, focuses on the approaches used and lessons learned by researchers conducting care transitions studies funded by the Patient-Centered Outcomes Research Institute (PCORI). PCORI's approach to transitional care research augments prior research by encouraging researchers to focus on head-to-head comparisons of interventions, the use of patient-centered outcomes, and the engagement of stakeholders throughout the research process.

Objectives: This paper introduces the themes and topics addressed by the articles that follow, which are focused on opportunities and challenges involved in conducting patient-centered clinical comparative effectiveness research in transitional care.

Patient and Family Engaged Care: An Essential Element of Health Equity.

In this paper, we emphasize and explore health equity as an integral component of a culture of patient and family engaged care (PFEC), rather than an isolated or peripheral outcome. To examine the role of PFEC in addressing health inequities, we build on the 2017 NAM Perspectives discussion paper "Harnessing Evidence and Experience to Change Culture: A Guiding Framework for Patient and Family Engaged Care." Informed by both scientific evidence and the lived experience of patients, their care partners, practitioners, and health system leaders, the paper by Frampton et al.

Aging: adding complexity, requiring skills.

The role of systems in addressing the needs of elderly and chronically ill populations remains a far from universal way of thinking, much less practice, in health care. Re-engineering the current fragmented system to align providers, patients and payment models to facilitate proactive management of conditions associated with advanced age and/or one or more chronic diseases - rather than responding to costly consequences of a health care system optimized for acute care conditions - will be a major challenge for all stakeholders. There are, however, promising success stories that are taking place in the United States today that may provide a model for improvement.