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.
Understanding The Care Transitions Intervention Model
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
Measuring the Success of the Care Transitions Intervention
The Rochester 2020 Performance Commission and The Care Transitions Intervention
Medical Orders for Life-Sustaining Treatment (MOLST) Program
Community Health Foundation of Western & Central NY
Supported by a grant from the Community Health Foundation of Western and Central New York. The Community Health Foundation is a non-profit private foundation the mission of which is to improve the health and health care of the people of Western and Central New York.
- 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)
California Healthcare Foundation
Research & References
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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)
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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.
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One patient, Many Places: Managing Health Care Transitions. A report from the HMO Workgroup on Care Management (2004).
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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.
Consumer Information
Eric Coleman, MD, MPH is a Professor of Medicine within the divisions of Health Care Policy and research and Geriatric Medicine at the University of Colorado Denver. Dr. Coleman is the Director of the Care Transitions Program, aimed at improving quality and safety during times of care “hand-offs”. He is also the Executive Director of the Practice Change Fellows Program, designed to build leadership capacity among health care professionals who are responsible for geriatric programs and service lines. As a board-certified geriatrician, Dr. Coleman maintains direct patient care responsibility for older adults in ambulatory, acute, and subacute care settings.
Dr. Coleman’s research focuses on: (1) enhancing the role of patients and caregivers in improving the equality of their care transitions across acute and post-acute settings; (2) measuring quality of care transitions from the perspective of patients and caregivers; and (3) implementing system-level quality improvement interventions and (4) using health information technology to promote safe and effective care transitions.
For more information, please go to www.caretransitions.org or www.practicechangefellows.org
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