The Care Transitions InterventionSM is designed to address the care needs of a targeted patient population that meets the following criteria:
- Age 65 or older
- Hospital admission for non-psychiatric-related condition
- Community dwelling
- Reside within defined geographical area (to enable home visits)
- Have a working telephone
- Have a condition that typically requires post-discharge SNF or home health care or intensive anticoagulation management. Specifically, have at least one of the following conditions documented in their medical record: congestive heart failure, chronic obstructive pulmonary disease, coronary artery disease, diabetes, stroke, medical and surgical back conditions (predominantly spinal stenosis), hip fracture, peripheral vascular disease, cardiac arrythmias, deep venous thrombosis, and pulmonary embolism.
The Care Transitions InterventionSM was developed by a professor at the Division of Health Care Policy and Research at the University of Colorado Health Sciences Center. Testing of the model was conducted at a large integrated health system in Colorado and in a mixed traditional Medicare fee-for-service and IPA practice in Colorado.
This model is designed to help patients more effectively manage significant transitions in their care, primarily from the hospital to home or from the hospital to a skilled nursing facility to home.
