The Care Transitions Intervention
Improving Quality and Safety During Hand-Offs
The focus of The Care Transitions Intervention encourages patients and family caregivers to assert a more active role during care hand-offs.
The Intervention Focuses on Four Conceptual Domains Referred to as Pillars:
- Medication self-management
- Use of dynamic patient-centered record, the Personal Health Record
- Timely primary care/specialty care follow up
- Knowledge of red flags that indicate a worsening in their condition and how to respond
Patients who receive this program were significantly less likely to be readmitted to the hospital, and the benefits were sustained for five months after the end of the one-month intervention.
The "Fith Pillar": Advance Care Planning
- End-of-Life Care Transition Program: Two-Step Advance Care Planning: Community Conversations on Compassionate Care (CCCC) and Medical Orders for Life-Sustaining Treatment (MOLST) Program
- Dr. Bomba's Presentation on the Fith Pillar to the Rochester Community 09/15/09
Medical Orders for Life-Sustaining Treatment (MOLST) Program
- Senior Centered Care: Programming for Older Adults [pps]
(Care Transitions Intervention for CHF Patients at Crouse Hospital)
Quality Improvement Collaborative to Benefit Frail Elders (04/2007 - 09/2008)
Research & References
Eric A. Coleman, MD, MPH; Carla Parry, PhD, MSW; Sandra Chalmers, MPH: Sung-joon Min, PhD (2006) The Care Transitions Intervention, Results of Randomized Controlled Trial. ARCH INTERN MED/VOL 166, 1822-1828. (link to PDF)
Stephen F. Jenks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H. (2009) Rehospitalizations among Patients in the Medicare Fee-for-Service Program. The New England Journal of Medicine 360:1418-28.
One patient, Many Places: Managing Health Care Transitions. A report from the HMO Workgroup on Care Management (2004).
An Interdisciplinary Team Approach to Improving Transitions Across Sites Of Geriatric Care. Published by the University of Colorado Health Sciences Center Division of the Health Care Policy and Research Denver, Colorado.