What is transitional care and how does it related to integrated care?
Transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Transitional care and integrated care are interwoven with integrated care providing the infrastructure for how care is organized and transitional care providing the linkages between settings of care, inclusive of the patient’s home.
What is the focus of The Care Transitions Program® and how does it operate?
The Care Transitions Program® was established in 1998 by Dr. Eric A. Coleman who continues to serve as its Director. Since inception, the Program has made a commitment to obtain input from patients and family caregivers to co-design each new initiative and this has proven instrumental to the wide adoption of its many endeavors. To date the program has made over 20 unique contributions to the field. Initially supported through the generosity of The John A. Hartford Foundation, The Robert Wood Johnson Foundation, and the Gordon and Betty Moore Foundation, the Program is now self-sustaining through training and technical assistance efforts.
How do you foster greater engagement among patients and family caregivers?
The flagship evidence-based Care Transitions Intervention® (CTI®) is unique in its explicit focus on the use of simulation as a means to foster improved self- care management among patients and family caregivers. In this regard, the CTI® has also become known as The Skill Transfer Model®. Outcomes include 25-50% reductions in readmissions, improved patient activation, and high rates of personal goal attainment. The CTI® has proven to be scalable, having been adopted by over 1000 leading health care organizations in the United States where it has been tailored to diverse patient populations. The model has also been adopted in Australia, Canada, and Singapore.
How do you determine high quality transitional care?
The NQF-endorsed 3-item Care Transitions Measure ® (3-item CTM®) has been incorporated into the U.S. HCAHPS hospital consumer experience tool and as such is used in every U.S. hospital that participates in the Medicare program (over 4000 hospitals). At its core, the 3-item CTM® ascertains the extent to which patients feel prepared to return home. Low scores on the measure predict recidivism. The CTM® has been translated into over 25 languages. The initial measure development was presented at the inaugural IFIC meeting in Strasbourg 2002.
How do you promote the role and identity of family caregivers?
The Family Caregiver Activation in Transitions ® (FCAT®) Tool was designed to facilitate more productive interactions and guide the care team in understanding and family caregiver needs and deploying appropriate resources. The 10-item tool takes less than two minutes to administer.
What does the future hold in your efforts to improve transitional care?
This year we are unveiling our new on-line Goals Curriculum. We continue to promote how incorporating principles of simulation care can better prepare patients and families to be successful in their self-care upon returning home. Finally, we are exploring how the concept of feedback loops may represent a unifying construct for how we improve transitional care.
To contact us or to learn more please visit www.caretransitions.org
Eric A. Coleman
Eric A. Coleman, MD, MPH, is Professor of Medicine and Head of the Division of Health Care Policy and Research at the University of Colorado Anschutz Medical Campus. Dr. Coleman is the Director of the Care Transitions Program, aimed at improving quality and safety during times of care “handoffs”
Eric will be a keynote speaker at ICIC18 in May