"My Transitions Coach® has helped me to feel more confident in managing my heart condition. I feel as though I am in charge of my health and I am less reliant on others."
~ patient testimonial

Program Structure

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 the transition.

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

  1. Medication self-management: Patient is knowledgeable about medications and has a medication management system.
  2. 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.
  3. 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.
  4. 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

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