Transitional Care in Later Life: Improve the Move

Transitional care is the set of actions designed to ensure coordination and continuity of healthcare as patients transfer between different locations. Transitional care includes logistical arrangements, preparation of the patient and family for self-care, and coordination among the health professionals involved in the transition (Coleman and Boult, 2003). A TIME OF HEIGHTENED VULNERABILITY Management of acute and chronic illnesses commonly requires patients to move to several different care settings during an episode of illness. The brief window of time when a patient changes settings can be a vulnerable period, making a successful transition as important to a patient's recovery as the healthcare delivered. Many of these transitions result from unexpected incidents and involve care practitioners who do not have ongoing relationships with the patient. The incidents can occur day or night and often happen so quickly that family caregivers, care managers, or others who make up the patient's existing support structure are not able to respond in a timely manner. These characteristics make it difficult for planning by either the patient or the healthcare system. As patients are moved from one care setting to another, they arc at risk for medication errors, duplication of services, and unnecessary use of high-intensity care settings such as emergency departments and hospitals. Researchers at the University of Colorado Health Sciences Center (UCHSC) Care Transitions Program are examining interventions to overcome this vulnerability and identify new approaches for improving outcomes for patients during transfers. Recent advances have led to new models of care and tools designed to identify care deficiencies, promote quality improvement, and enhance the care experienced by older adults during transitions. The Care Transitions Program maintains that improving transitional care will require intervention at multiple levels-patient, practitioner, delivery system, and policy maker. PATIENT Innovative care models developed to support patients and family caregivers are needed to improve care transitions. The centerpiece of the UCHSC Care Transitions Program is the Care Transitions Intervention. This model recognizes that patients are the only common thread among different sites of care and provides patients with skills and tools for assuming a more active role in their own transitions (Parry et al., 2003; Coleman et al., 2004). Patients and family caregivers are supported by a transition coach, typically a registered nurse or advanced practice nurse who moves with the patient across settings for up to thirty days after hospital discharge. During this time, the coach arranges for a home visit, and two or three follow-up telephone calls. Coaches focus their attention on reconciling and managing medication, assisting patients with completing a personal health record of core information, ensuring that timely follow-up care occurs, and helping patients recognize red flags that indicate their condition may be worsening and advising them on how to seek appropriate care. The Care Transitions Intervention was rigorously tested through a quasi-experimental trial followed by a two-year multisite randomized controlled trial under different payment structures (Coleman et al., 2006). During the randomized controlled trial, subjects were assigned to a control arm and an intervention arm. Those in the control group received the usual care, and those in the intervention arm received the Care Transitions Intervention. The two populations were compared for cost and use of healthcare services at 30, 90, and 180 days after their initial hospitalization. Patients receiving the intervention were significantly less likely to be readmitted to a hospital, with benefits being sustained for as long as six months. Similarly, total hospital costs were also significantly reduced over the six-month time period. These positive results have stimulated the interest of the healthcare community, creating demand for application in an array of venues. …