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Care Transitions Model:

The Four Pillars of Care Transitions

During the four-week Care Transitions program, patients with complex care needs and family caregivers work with a "Transition Coach" and learn self-management skills that will ease their transition from hospital to home. The coach is an advanced practice nurse or a registered nurse who has received training in the Care Transitions Intervention program. This intervention is centered on four pillars:


1. Medication self-management
2. The Personal Health Record
3. Timely primary care/specialty care follow up
4. Knowledge of red flags that indicate a worsening in their condition and how to respond

A low-tech but highly effective tool developed by the Care Transitions team-the Personal Health Record- helps patients track prescriptions and instructions from their different doctors and other health care providers. By bringing the record to each visit, patients can keep their different doctors informed and reduce the risk of rehospitalization or medication errors. The transition coach visits the patient for the first time just prior to discharge from the hospital and then makes a home visit a few days later. During this home visit, the coach reviews all of the medications the patient is taking. If errors are detected or if the regimen is confusing or impractical, the coach helps the patient and family caregiver to communicate their questions and concerns to the relevant health care provider.

The coach also educates the patient about warning signs (red flags) that the patient's condition may be worsening and helps him or her to understand when to call the physician or other health care provider. If patients have particular questions or concerns about their care, if they've received conflicting instructions from different care providers, or if they simply need clarification about something, the coach supports them in communicating with their care providers.

The coach also instructs the patient in the use of the Personal Health Record, in which the patient records medicines and administration schedules, allergies, instructions from health care providers, red flags for his or her disease, and questions and concerns to discuss at future health care visits.

Structured visits and phone calls by the coach promote safe transitions during the critical first month at home following a hospitalization. The patient is encouraged to call the coach at any time with questions.

For patients discharged from the hospital to a skilled nursing facility, once weekly the coach visits the skilled nursing facility until the patient returns home.

"Patients really have a chance to regain their independence through this program," says Kathryn Botinelli, Transitions Coach, Centura Home Health, Denver, Colorado. She has witnessed the change in patients from being confused and overwhelmed to feeling confident and being active participants in their own healing. "The program, and particularly the Personal Health Record, helps them to feel that they can talk to the doctor instead of just being talked at by the doctor," she says.

While the Care Transitions program lasts for just one month, the impact has been shown to be more long-lasting. The patients who participate in the program have complex chronic illnesses and therefore are at high risk for repeat hospitalizations. They use the self-management skills learned during the program in subsequent episodes of care transitions.
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