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Transitions between and within healthcare settings have been identified as a cause of harm to patients because of communications breakdowns and lack of continuity in care[1]. Care transitions programs establish seamless transitions between facilities and seek to help patients better manage transitions from one care setting to another.

A key focus of many care transitions programs is the reduction of hospital readmissions by improving post-discharge care and patient compliance with follow up care recommendations. One of the best ways for communities to reduce healthcare costs quickly and improve patient care in the process is to implement initiatives to reduce hospital readmissions. Research studies and quality-reporting initiatives around the country show that 15-25% of people who are discharged from the hospital will be readmitted to the hospital within 30 days or less, and that many of these readmissions are preventable.[2]  Across the country, hospitals, clinics, long term care facilities and other health care and patient support agencies are developing models of care that aim to:

  • improve processes of care at a system level
  •  identify specific diseases or conditions that lead to readmissions, and
  • address community-specific reasons for readmissions.[3]

Evidence-Based Models/Approaches

The American Geriatrics Society defines care transitions this way:

Transitional care is defined as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location…Transitional care is based on a comprehensive plan of care and the availability of health care practitioners who are well-trained in chronic care and have current information about the patient’s goals, preferences, and clinical status. It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.

There are a variety of evidence-based care transition models that focus on ensuring coordination and continuity of care as a patient transfers between different health care settings and levels of care.  These models all share a core set of components that must be present for this approach to be successful:

  • Interdisciplinary communication and collaboration across agencies and between providers
  • Dedicated transitional care staff (e.g. patient navigator, care coordinator, etc.) focused on coordinating transitions with patients and their families and between healthcare agencies
  • Focus on patient activation –  the level of patient knowledge, skills and confidence to manage their own health and health care[1]
  • Provision of enhanced followup to continue to support patients through contact from providers, home visits, phone calls and other methods of contact.

Some of the evidence-based care transitions models most commonly implemented by organizations, health systems and health collaboratives include:  

  • The Project BOOST® Mentored Implementation Program is a national initiative led by the Society of Hospital Medicine (SHM) to improve the care of patients as they transition from hospital to home.
  • Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program ® is to: support patients and families; increase skills among healthcare providers and teach patients self-management skills that will ensure their needs are met during the transition from hospital to home.
  • The Transitional Care Model (TCM), designed by Dr. Mary Naylor and a multidisciplinary team of colleagues at the University of Pennsylvania, addresses the negative effects associated with common breakdowns in care when older adults with complex needs transition from an acute care setting to their home or other care setting, and prepares patients and family caregivers to more effectively manage changes in health associated with multiple chronic illness.
  • The Bridge Model is a person-centered, social work-led, interdisciplinary model of transitional care. The Bridge Model emphasizes collaboration among hospitals, community-based providers, and the Aging Network in order to ensure a seamless continuum of health and community care across settings.[A1]  This model promotesa just system of long-term services and supports that enables people to live according to their own goals and values, without exploiting others.
  • GRACE Team Care  improves the health — and lives — of frail older adults with complex needs. Working together, a team of doctors, nurses, social workers, and pharmacists use geriatric knowledge and techniques to improve patient care — not just in the clinic, but in the patient’s home and community.GRACE (Geriatric Resources for Assessment and Care of Elders)
  • Guided Care [A2] ® helps primary care practices meet the complex needs of patients with multiple chronic conditions.  In this proven care model, a trained Guided Care nurse works closely with patients, physicians and others to provide coordinated, patient-centered care. 


The Centers for Medicaid and Medicare Services’ Community-based Care Transitions Program (CCTP) was created by Section 3026 of the Affordable Care Act. The program tests models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. The website has resources and case studies from across the country:

Funding Sources

There are new opportunities through CMS to receive reimbursement for work around care transitions.

  • Chronic Care Management Program (CCM):  CCM is a new code that became available 1/1/15. As part of its growing emphasis on primary care and chronic care management, Medicare began paying for certain non-face-to-face care management services provided to Medicare beneficiaries covered under the traditional Medicare fee-for-service program. These Chronic Care Management services include, but are not limited to, development and maintenance of a plan of care, communication with other health professionals, and medication management. Here is a link to more information:


Chautauqua Health Connects is an initiative funded through the Office of Rural Health Policy’s Rural Health Care Services Outreach Program to improve interdisciplinary communication and collaboration through an intra-county health information exchange to support high-quality care management. With a goal of improving coordination of services for seniors and allowing them to remain in their homes, Chautauqua County Health Network collaborates with over twenty healthcare organizations to create the infrastructure and resources. Chautauqua Health Connects involves linking organizations through a Health Insurance Portability and Accountability Act (HIPPA) compliant web-based health information exchange, training and deploying nurse care managers and/or care coordinators, and standardizing communication procedures between organizations. The exchange enables the electronic transfer of secure messages and referrals, improving information flow and strengthening communications among health care providers and community based services.  Organizations are trained on the importance of implementing best practices that will result in improved healthcare and health. Tools include but are not limited to: Patient Centered Medical Home, Aging and Disabilities Resource Centers, Chronic Disease Self-Management, Guided Care Solutions, the Chronic Care Model, and health information exchange.

Providence Kodiak Island Medical Center has created a staff position dedicated to coordinating transitions with patients and their families and between healthcare agencies. A project funded through the Office of Rural Health Policy’s Small Healthcare Provider Quality Improvement Program provides cost effective care coordination by linking a registered nurse from Providence Kodiak Island Medical Center (PKIMC) with patients served in the Kodiak Community Health Center (KCHC). Using the Johns Hopkins University model of Guided Care, an experienced registered nurse has been fully integrated into the primary care setting at KCHC to work alongside primary care providers to provide complex health care coordination for up to 60 of their high-risk patients.   The nurse works in partnership with several primary care physicians to provide coordinated, patient-centered, and cost effective care of patients in collaboration with staff at the KCHC and PKIMC.  The nurse further facilitates patient navigation within the healthcare system. She acts as the liaison for access to community resources; coordinates the continuity of patient care with external healthcare organizations; coordinates transitional care for patients and their families following hospital discharge and emergency department visits;  promotes clear communication among care teams and treating providers by ensuring awareness regarding patient care plans; and is responsible for program outreach both within the primary care setting as well as through community venues.

[1] Gabriel Perna. Mounting Evidence in Favor of Patient Activation. Healthcare Informatics. Accessed at:

[1] Lindsay, M., et al. New Models for Rural Post-Acute Care : Critical Access Hospitals Optimize Patient Outcomes, Value, And Financial Stability. Accessed at:

[2] Center for Healthcare Quality and Payment Reform. Reducing Hospital Readmissions. Accessed at:

[3] Centers for Medicare and Medicaid Services. QIO Recent Accomplishments: Care Transitions. Accessed at:

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