With funding from The John A. Hartford Foundation
and The Robert Wood Johnson Foundation, the Care Transitions Intervention®
was designed in response to the need for a patient-centered,
interdisciplinary intervention that addresses continuity of care across multiple settings and
practitioners. The overriding goal of the intervention is to improve care transitions by providing
patients with tools and support that promote knowledge and self-management of their condition as they
move from hospital to home.
The model is composed of the following components:
- A patient-centered record that consists of the essential care elements for facilitating
productive interdisciplinary communication during the care transition (referred to as the
Personal Health Record, or PHR).
- A structured checklist (Discharge Preparation
Checklist) of critical activities
designed to empower patients before discharge from the hospital or nursing facility.
- A patient self-activation and management session with a Transitions Coach®
in the hospital-designed to help patients and their caregivers understand and apply
the first two elements and assert their role in managing transitions.
- Transitions Coach® follow-up visits in the Skilled Nursing Facility (SNF) and/or in the home and
accompanying phone calls designed to sustain the first three components and provide continuity across
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
||Dynamic Patient-Centered Record
||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
||Discuss importance of knowing medications
||Recommend Primary Care Provider follow-up visit
||Discuss symptoms and drug reactions
||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
||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
© 2007 Care Transitions Program; Denver, Colorado.
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.
© Eric A. Coleman, MD, MPH