Organizations interested in adopting the model are encouraged to visit www.caretransitions.org to request an introductory DVD, download the manual, review the tools for Transition Coaches and patients/family caregivers, and to learn more about the model (all are available at no cost). Those organizations that are interested in pursuing adoption are then encouraged to first secure the support of senior leadership and begin to identify who will perform the role of the Transition Coach(es). Once this has been determined, organizations are encouraged to contact the Care Transitions InterventionSM via www.caretransitions.org.
The Care Transitions InterventionSM started with an APN with self-management training as one of its initial coaches. The program also recruited home health care RNs, who are comfortable working autonomously and in patients’ homes, and RNs who had worked in disability, who were used to moving people from health care institutions to the home.
Advance Practice Nurses, Registered Nurses, and Social Workers have all successfully performed the role of the Transitions Coach. Social Workers have generally benefited from having real time access to pharmacy expertise.
The University of Colorado is in the process of developing a training program for Transition Coaches. Please check their website, www.caretransitions.org, for current information.
The process of selecting patients for The Care Transitions InterventionSM varies by organization. Some model adoptees send Transition Coaches into the hospital to identify patients who meet the criteria (described on the Overview page) and could benefit from the intervention. Other organizations educate hospital discharge planners on the patient selection criteria and have the discharge planners identify patients; in many of these cases, the discharge planners confer with the Coaches by phone.
The Care Transitions InterventionSM has been adopted by over 100 health care organizations nationwide. To date, no two organizations have been alike.
The California HealthCare Foundation provided funding for ten sites in the state of California to implement The Care Transitions InterventionSM. These organizations intend to use different types of individuals as Transition Coaches, including nurses, social workers and nursing students.
In addition, the Community Health Foundation of Western and Central New York funded 13 teams in the greater upstate New York area to implement the model (this has also filled its slots and will conclude in October 2008.
The Care Transitions InterventionSM has broad appeal for replication, due to the relatively low intensity and low cost of implementing the model. Since the model’s primary cost savings result from prevented readmissions, organizations considering this model need to determine whether they will actually realize savings from fewer hospital admissions. With new national initiatives aimed at public reporting of hospital (risk-adjusted) 30-day readmission rates, the model has additional appeal for its potential to improve the public image of a hospital.
