Improving Care Transitions
and Reducing Rehospitalizations

Several evidence-based models that address high rates of readmissions within 30 days of discharge have emerged. Links to programs with widely available implementation toolkits or other helpful information are below. 
 

Resources and links

The Transitional Care Model (TCM)

Mary D. Naylor, PhD, RN, FAAN
Marian S. Ware Professor in Gerontology
Director, NewCourtland Center for Transitions & Health
University of Pennsylvania School of Nursing

The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. The heart of the model is the Transitional Care Nurse (TCN), who follows patients from the hospital into their homes. While TCM is nurse-led, it is a multidisciplinary model that includes physicians, nurses, social workers, discharge planners, pharmacists and other members of the health care team in the implementation of tested protocols with a unique focus on increasing patients' and caregivers' ability to manage their care.

The Care Transitions Program

Eric A. Coleman, MD, MPH
Director, Care Transitions Program
University of Colorado Denver
The aim of the Care Transitions Program^® is to:

►  Support patients and families

►  Increase skills among healthcare providers

►  Enhance the ability of health information technology to promote health information exchange across care settings

►  Implement system level interventions to improve quality and safety

►  Develop performance measures and public reporting mechanisms; and
influence health policy at the national level


Project BOOST (Better Outcomes for Older adults through Safe Transitions)

A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home. Objectives are to:

  ► Identify high-risk patients on admission and target risk-specific interventions

  ► Reduce 30 day readmission rates for general medicine patients

  ► Reduce length of stay

  ► Improve facility patient satisfaction and H-CAHPS scores

  ► Improve information flow between inpatient and outpatient provider

Colorado Foundation for Medical Care

The web site of Colorado's Medicare Quality Improvement Organization offers a wealth of free, downloadable high quality resources, including a terrific search engine.

National Transitions of Care Coalition

NTOCC is a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care. It is was founded in 2006 by the Case Management Society of America and sanofi-aventis.

      ► to:      
The site features a robust compendium of resources.