As we age we hope to remain at home and independent for as long as possible.  Most people see the health care system as an important contributor to their ability to maintain this independence. Unfortunately, as we get older we become more susceptible to harm from a lack of coordination and communication between our health care team members.  Different health care settings do not have access to the same information. This can lead to expensive duplication of services, or worse, to actual harm when one clinician doesn’t know a patient’s medical history or his or her current medications.  In short, transitions of care between health care providers and settings are fraught with risk, particularly to the health and safety of older adults.

We at the John A. Hartford Foundation have supported the development, testing, and dissemination of evidence-based approaches that improve transitions of care.  For over a decade we have invested more than $26.4 million in innovators such as Eric Coleman, Mary Naylor, Mark Williams, June Simmons and others.

As a result of their work, a grandmother in Texas living with congestive heart failure was discharged from the hospital knowing that a sudden weight gain was a “red flag” that she should urgently report to her primary care team.  Her physician knew she was coming home.  A transitions coach arranged a follow-up appointment with her doctor before she was discharged.  Both the physician and the family had a current list of her medications from the hospital, and the Aging and Disability Resource Center in her community knew what supports and services she would need at home.  When she started to retain fluid and gain weight, her health care team responded and kept her from returning to the hospital.   The patient and the health care team together helped her remain well and independent at home.

Health information technology (IT) is a critical component of a good transition.  With an electronic health record, the grandmother in Texas could more quickly share her records with all of her providers.  With automated decision-support systems, her physicians would more easily know if her combination of medications might be dangerous.  Yet those providing health care and social supports rarely get the opportunity to engage in discussions with clinical innovators developing new care approaches focused on improving transitions, nor with those on the cutting edge of information technology.

In order to address these challenges, the John A. Hartford Foundation is partnering with the Gordon and Betty Moore Foundation and Kaiser Permanente to convene key stakeholders in the innovation, health care provider, and IT vendor communities.  Media partners for the event are Health Affairs and Health 2.0.  The Office of the National Coordinator for Health IT (ONC) at the Department of Health and Human Services (HHS) and the HHS Partnership for Patients Initiative are key participants. Conference participants will identify: (1) best practices using health IT that can be implemented immediately to improve care transitions; (2) best practices that can be implemented within a year, and; (3) an agenda outlining large opportunities where health IT innovation can address persistent barriers to progress.

The convening will be held in Washington, D.C., on October 14, 2011, from 8am-3pm. Speakers include Farzad Mostashari, Todd Park, and Eric Coleman.

Modeling good use of technology, the Hartford Foundation encourages participation not only through webcast for those unable to participate in person, but also through Facebook, Twitter, and LinkedIn: sign up here.  We have engaged Brian Ahier, a health IT professional and blogger, to serve as our host in the blogosphere and twittersphere.  Please follow the conference on Twitter @ahier and @jhartfound, and use the hashtag #ITrans in your tweets.  For more information, please e-mail You can also view the press release here.

Together, with your help, we can figure out how best to craft and use IT to support seamless Care TransITions.