A Care Transitions™ Primer

Apr 18, 2012

Care Transitions™ can be defined as the movement of patients from one healthcare provider or setting to another as condition and care requirements change during the course of an acute or chronic illness.  The two key goals for a successful care transition are:

  • To empower individuals and families to take an active part in their healthcare, and
  • To reduce hospital re-admissions.

Eric Coleman, MD, MPH, is the Director of the Care Transitions Program at the University of Colorado Denver.  Dr. Coleman notes that care that prevents rehospitalizations occurs largely outside a hospital, but begins in the hospital.  He also notes that a typical patient has a nearly 2/3 chance of being re-hospitalized or of dying within a year after discharge.  As we have already mentioned in previous blogs, there are four specific target diagnoses:  Acute Myocardial Infarction, Congestive Heart Failure, chronic Obstructive Pulmonary Disease (COPD) and Pneumonia.

Dr. Coleman recommends a deliberate "intervention" to facilitate the care transition, and identifies Four Pillars, or guidelines for the patient:

  • Medication Self-management
  • Personal health record that is  a portable and easy to understand
  • Follow-up appointment with primary physician or specialist
  • Knowledge of "red flags" or warning signs/symptoms with respect to a patient's diagnosis

Stay tuned for a brief discussion of each of these pillars!