"Care Transitions: When getting there is not half the fun."
~ Robert Wood Johnson Foundation website


Case 1:
An older woman is hospitalized for an elective surgery of her back. Following surgery, she is sent home late on a Friday evening without an adequate supply of pain medications to last over the weekend. Her daughter (who flew in to town to care for her mother) could not reach the orthopedist and spent hours making phone calls and driving around to obtain additional pain medication. In addition to her pain medications, she received conflicting information about which medications she could take and if and when she could bathe. Further, she was sent home without advice or treatment to keep her from becoming constipated; she did not have a bowel movement for 8 days.

Case 2:
Another older woman had back surgery and was sent home without instructions for how to care for herself and without home health care services. She had great difficulty getting out of bed to use the toilet, she could not take care of the surgical wound on her back, and she could not prepare meals for herself. She was frightened and did not know who to call for help.

Case 3:
An older woman had a stroke and was discharged from the hospital to home without any plan for follow up care. Her primary care physician was not notified of her recent hospitalization or new diagnosis. The patient's condition worsened and she had to be readmitted to the hospital within a few days.

Case 4:
An older woman was found to have severe blockage of several of the blood vessels that supply her heart. She was told that she would need heart surgery and this was scheduled to occur within the next 2 weeks. However, she was discharged from the hospital without any advice about whether she needed to abide by any activity restrictions to avoid stressing her vulnerable heart while awaiting surgery. She also lacked information about what her care needs would be after the surgery (i.e., would she need to go to a rehabilitation facility? would she need to give up her home? How would all of this be paid for?). Both the patient and family were very anxious and felt abandoned by the health care system.

Case 5:
An older woman experienced multiple hospitalizations after having a major complication during surgery. Because she recognized that no one was taking charge of her care, she decided that she needed to and kept track of her medications (she was on over 16 medications and none of her physicians could keep them all straight), her follow-up appointments and tests, and became her own spokesperson. She is an extremely eloquent individual who can speak to the patient's role in assuring smooth transitions.

Case 6:
An older man who takes medication to thin his blood to prevent a future stroke is hospitalized for an unrelated condition. Because the doctors in the hospital don't know what the usual dose of his blood thinning medication was before the hospitalization and they do not contact the nurse that monitors this medication, they inadvertently change the dose and send him home. The new dose turns out to be twice as potent as his usual dose and within two days he is rehospitalized with uncontrollable bleeding.

Case 7:
(This case illustrates the virtues of our study intervention designed to assure smooth transitions) An older man was discharged from the hospital with incomplete discharge instructions. Consequently he did not understand what medications he should take, when he needed to see his doctor in follow-up, what laboratories he needed. He didn't know how to obtain refills on his medications and because he did not get along with his primary care physician, he didn't want to go in for an appointment. Although a visiting nurse was sent out to his home, she did not know what medications he should be taking or what his follow-up needs were.
His transition coach® came out to his home the day after hospitalization and reviewed his current medication needs in detail, helped him obtain refills and critical follow up laboratory studies, assisted in his transfer to a new primary care physician, and referred him to a longitudinal care management program. His health status improved and he remained out of the hospital.

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