The Care Transitions Program®

The intervention focuses on four conceptual areas, referred to as The Four Pillars^®:

Medication self-management: Patient is knowledgeable about medications and has a medication management system.
Use of a dynamic patient-centered record: Patient understands and utilizes the Personal Health Record (PHR) to facilitate communication and ensure continuity of care plan across providers and settings. The patient or informal caregiver manages the PHR.
Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visit with the primary care physician or specialist physician and is empowered to be an active participant in these interactions.
Knowledge of Red Flags: Patient is knowledgeable about indications that their condition is worsening and how to respond.

*Pillar:*	Medication Self-Management	Dynamic Patient-Centered Record	Follow-Up	Red Flags
Goal	Patient is knowledgeable about medications and has system	Patient understands and manages a Personal Health Record (PHR)	Patient schedules and completes follow-up visit with Primary Care Provider/Specialist	Patient is knowledgeable about indications that condition is worsening and how to respond
Hospital Visit	Discuss importance of knowing medications	Explain PHR	Recommend Primary Care Provider follow-up visit	Discuss symptoms and drug reactions
Home Visit	Reconcile pre- and post-hospitalization medication lists Identify and correct any discrepancies	Review and update PHR Review discharge summary Encourage patient to share PHR with Primary Care Provider and/or Specialist	Emphasize importance of the follow-up visit Practice and role-play questions for the Primary Care Provider	Discuss symptoms and side effects of medications
Follow-Up Calls	Answer any remaining medication questions	Discuss outcome of visit with Primary Care Provider or Specialist	Provide advocacy in getting appointment, if necessary	Reinforce when/if Primary Care Provider should be called

The intervention design is outlined in detail in the publication: Parry C, Coleman EA, Smith JD, Frank JC, Kramer AM. The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care. Home Health Services Quarterly. 2003;22(3):1-18.

The findings of the intervention are detailed in the publication Coleman EA, Smith JD, Frank JC, Min S, Parry C, Kramer AM. Preparing Patients and Caregivers to Participate in Care Delivered Across Settings: The Care Transitions Intervention. Journal of the American Geriatrics Society. 2004;52(11):1817-1825.

The Care Transitions Intervention^® and all of its materials are the property of the Care Transitions Program^®. The Care Transitions Program^® is solely authorized to provide training on the Care Transitions Intervention^®. If another entity offers to train your organization, please contact us.