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Implementation of the Care Transitions Intervention: Sustainability and Lessons Learned

Parrish, Monique M. DrPH, MPH, MSSW; O'Malley, Kate MS, RN, GNP; Adams, Rachel I. BS; Adams, Sara R. MPH; Coleman, Eric A. MD, MPH

doi: 10.1097/NCM.0b013e3181c3d380

Purpose: During care transitions, the movement of patients from one healthcare practitioner or setting to another, patients are vulnerable to serious lapses in the quality and safety of their medical care. The Care Transitions Intervention (CTI), a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from the acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self-management needs are met, was implemented in 10 hospital–community-based partnership sites in California over a 12-month period. Five of the partnerships were hospital-led sites, and 5 were county-led sites. The primary goal of the project was to identify factors that promote sustainability of the intervention by (1) assessing features of each site's implementation and the site's likelihood of continuing the program; (2) soliciting feedback from the sites; and (3) analyzing site and patient characteristic data and data from the CTI measurement instruments (the 3-item Care Transition Measure [CTM-3] and the Patient Activation Assessment [PAA] tool).

Primary practice setting(s): The CTI was implemented in 10 California hospital and community-based organizations that received training and technical support to implement the intervention.

Findings: Presence of leadership support was determined to be the critical factor for sites reporting interest in and capacity for long-term support of the CTI. Sites identified engaging hospital- and community-based leaders, providing additional transition coach training, and the assigning of consistent and dedicated (funded) transition coaches as valuable lessons learned. Key findings from the measurement instruments indicate that future CTI implementations should focus on medication management, patients with cardiovascular conditions and diabetes, patients older than 85 years, and African American and Latino patients. Mean PAA scores were moderately higher for patients from hospital-led sites than for patients from county-led sites and moderately higher for patients from sites with full plans for continuation than for patients from sites with partial or minor plans to continue the CTI.

Implications for case management practice: This implementation of the CTI, with its flexible design responsive to the diverse needs of patients, hospitals, and community organizations, provides a host of real-world lessons on how to improve and sustain effective patient transitions between care settings. Healthcare systems interested in improving care transitions have a compelling reason to explore the viability of implementing the intervention with attention to developing or addressing the following: strong care transitions leadership; collaborative hospital–community partnerships; the particular needs of diverse communities; patient-level medication reconciliation and management; and tailoring the model to the unique needs of patients with cardiovascular conditions and diabetes.

Monique M. Parrish, DrPH, MPH, MSSW, is Director of LifeCourse Strategies, Orinda, California, a consulting firm specializing in strategic planning, community-based research, program development, and policy analysis for the aging and long-term care field.

Kate O'Malley, MS, RN, GNP, is a senior program officer with the Oakland-based California HealthCare Foundation's Better Chronic Disease Care program, which focuses on improving the quality of care for Californians with chronic diseases.

Rachel I. Adams, BS, is a doctoral student in the Department of Biology at Stanford University, Palo Alto, California.

Sara R. Adams, MPH, is a statistical analyst who has worked at ICON Clinical Research and Cal/EPA Office of Environmental Health Hazard Assessment, Oakland, California.

Eric A. Coleman, MD, MPH, is Professor of Medicine within the Division of Health Care Policy and Research at the University of Colorado at Denver and Director of the Care Transitions Program, aimed at improving quality and safety during times of care “handoffs.”

Address correspondence to Monique M. Parrish, DrPH, MPH, MSSW, LifeCourse Strategies, Orinda, CA 94563 (

The authors have no conflict of interest.

This work was supported by a grant from the Oakland-based California HealthCare Foundation (grant number 06-1478).

© 2009 Lippincott Williams & Wilkins, Inc.