Research Projects

Aging and Serious Illness Projects

Aging Patients and Health Professionals: New Roles in a Changing Health System

Goal: To develop a measurement framework to compare professional roles and competencies of doctors, nurses and social workers in health care teams, and apply that framework to create optimal teams for the assessment and care of frail elders living in community settings. Funded by Gordon and Betty Moore Foundation

See: Donelan K, Chang Y, Berrett-Abebe J, Spetz J, Auerbach DI, Norman L, et al. Care Management For Older Adults: The Roles Of Nurses, Social Workers, And Physicians. Health Aff [Internet]. 2019 Jun 3 [cited 2019 Aug 22];38(6):941–9. Available from:

Variation in Case Management Programs and their Effectiveness in Managing High-Risk Patients for Medicare ACOs (with Dr. Joshua Metlay)

Goal: create a classification scheme to characterize existing case management programs and support future comparative effectiveness studies; extension aim to explore  roles of registered nurses and social workers in models of care management. Funded by PCORI

See: Donelan K, Barreto EA, Michael C, Nordby P, Smith M, Metlay J. Variability in Care Management Programs in Medicare ACOs. J Gen Intern Med. 2018 Jul 27. doi: 10.1007/s11606-018-4609-1.

Implementing 30-Day Post Discharge Community Health Worker Pairings for Patients at High Risk of Readmission (with Dr. Jocelyn Carter)

Goal:  Randomized trial of a community health worker intervention to reduce readmission, emergency visits and missed appointments

Improving Care for Persons with Disability Projects

Down Syndrome Clinic to You (DSC2U) Virtual Evidence-based Healthcare for Underserved Patients with Down Syndrome (with Dr. Brian Skotko)

Goal: To test the effectiveness of a virtual clinic in improving adherence to primary care standards of practice for patients with Down Syndrome to improve quality of care. Funded by PCORI 


Surveying Physicians to Understand Health Care Disparities  Affecting Persons with Disability and Identity Approaches to Improve their Care (with Dr. Lisa Iezzoni)

Goal:  To understand factors that contribute to health care disparities for persons with disability from the perspective of physicians practicing in outpatient settings and to use this understanding to develop a toolkit of practical suggestions for improving care. Funded by NIH

Persons with Disabilities Informing Quality of Care (with Dr. Lisa Iezzoni)

Goal: Test whether engagement of persons with disability in creating and communicating quality of life and health measures can change clinician practice and improve care from the perspective of patients with physical disability and serious mental illness. Funded by PCORI

Iezzoni LI, Chang Y, Matulewicz H, Heaphy D, Warsett KS, Donelan K. Health plan enrollees with disability informing primary care practices and providers about their quality of care: a randomized trial. Disabil Health J. 2018 Jul 24. pii: S1936-6574(18)30090-6. doi: 10.1016/j.dhjo.2018.05.006.