To improve patient transitions from one care setting to another, CHCF funded the implementation of the Coleman Care Transitions Intervention in 10 California communities.
In 2007, CHCF funded a one-year, $650,000 effort to improve care transitions in California. The approach selected for this project is the Coleman Care Transitions Intervention (CTI), based on the work of Eric Coleman, MD, from the University of Colorado. The project objective was to implement CTI in 10 California locations that would ultimately serve 1,000 patients and demonstrate how the model can be adapted to community programs.
CTI is a four-week process that encourages patients to take a more active role in their health care. Patients receive specific tools and skills that are reinforced by a "transition coach" (a nurse, social worker, or trained volunteer) who follows patients across settings for the first four weeks after leaving the hospital and focuses on the following components:
- Medication self-management
- Use of a patient-centered health record that helps guide patients through the care process
- Primary care provider and specialist follow-up
- Patient understanding of "red flag" indicators of worsening condition and appropriate next steps
In a randomized controlled trial, use of CTI resulted in lower hospital readmission rates: On average, for every 17 patients who work with a transition coach, one rehospitalization will be prevented. Researchers estimate that for every 350 patients who receive the intervention, hospital costs will be reduced by approximately $300,000. In addition, people who have used the care transitions model rate their hospital discharge experience as very good or excellent (Archives of Internal Medicine, September 2006).
The 10 implementations paired hospitals with local community organizations, listed below in that order. The primary grantee is indicated in bold type.
Huntington Memorial Hospital and Senior Care Network
- Cottage Health System and Santa Barbara Regional Health Authority
Saint Joseph's Hospital, Eureka, and Skilled Health Care (SNF), St. Joseph Home Care and St. Joseph Rehabilitation Center
- Dominican Hospital and Santa Cruz County Human Resources Agency
Cedars-Sinai Medical Center and Accredited Home Health Services
- John Muir Medical Center and John Muir Physicians Network
- Santa Rosa Memorial Hospital and Senior Advocacy Services and Sonoma County Human Services Agency
San Mateo Medical Center and San Mateo Aging and Adult Services
- Alameda County Medical Center and East Oakland Community Project
- Marin General Hospital and Marin County Department of Health and Human Services (Project Independence)
The original Request for Proposals is available under Document Downloads below.
Final Meeting Report
At the final grantee meeting, held in Sacramento on September 10, 2008, the project participants shared results with each other and state policymakers in the audience. They also considered next steps for expanding care transition improvements in California, bringing forward many suggestions, including:
- Look into regional approaches
- Use home health agencies more actively
- Figure out how to increase patients' motivation and demand for better care transitions
- Integrate funding for care transitions into larger funding schemes, and align incentives and payment mechanisms
- Educate all hospital personnel about care transitions, to engender systemwide support
- Promote the principle of personal responsibility, and provide early patient education and activation on how to use health care resources and manage health
- Document the successes, to show that the CTI model works and there's a financial payoff
In October 2007, Dr. Eric Coleman met with representatives from CHCF and the 10 project sites to begin to cull and share data at the project's midpoint. Among the findings from the meeting:
- The project sites show success in adapting the CTI model to diverse clients and environments. The CTI model makes use of the skills and talents of a variety of health care providers, including nursing students, social workers, and volunteers.
- There is evidence that a cross section of stakeholders recognize the utility of the CTI protocol.
- Implementing the intervention requires cultural change on both sides, so that community-based organizations and health care organizations can work together to improve patients' care transitions.
An interim report, available as a Document Download, describes these findings in more detail, as well as the comments by Dr. Coleman and meeting participants. It also provides information on each care transitions project and highlights participants' suggestions for areas for further inquiry.
Testimony Before the State of California
In October 2007, CHCF Senior Program Officer Kate O'Malley testified before the Assembly Committee on Aging and Long-Term Care, Assembly Committee on Health, and the California Commission on Aging joint hearing on improving hospital-to-home transitions for older adults and adults with disabilities. Her testimony is available under Document Downloads below.