Navigating Care Transitions in California: Two Models for Change

This is archived content; for historical reference only.

Care transitions occur when patients move between health care practitioners or treatment settings as their condition and care needs change. Such transitions may include moving from hospitals to nursing homes or home care after an acute illness, or moving from nursing homes to home care or even home with no formal care.

Too often, patients with complex acute or chronic conditions are ill-prepared for a care transition, which can compromise their health and raise the risk of readmission to the hospital.

To identify ways to promote effective care transitions in California, CHCF asked the authors to explore the models that have proved most effective. They interviewed representatives from health care organizations with a history of implementing best practices for patient populations with complex health care needs. The authors also facilitated a forum to provide a broader discussion of the strengths and weaknesses of two evidence-based pilot projects in California: the Coleman Care Transitions Intervention and the Naylor Transitional Care Model. The process yielded an outline of the advantages and disadvantages of the two models.

The full report is available under Document Downloads.