• Introduction
• Improving Care for the Chronically Ill
  • Improving Care of the Chronically Ill
  • Team Care Recognizes and Embraces Complexity
  • Team Care is Cost-Effective Care
  • Making Team Care the Standard of Care
• History of Commitment to Team Care
• Team Care Models
• Model 1: Care Transitions
  Improving Transitions Across Sites of Geriatric Care
  • Model 1: Care Transitions
    Improving Transitions Across Sites of Geriatric Care
  • The Four Pillars of Care Transitions
  • Illustration: Care Transitions Model
  • Measuring the Success of Care Transitions
  • Moving the Model from Two Sites to 100
  • A Transition Coach Makes Recovery from Surgery Faster, Easier
• Model 2: Care Management Plus
  Using Technology to Improve Outpatient Care for Older Adults
  • Model 2: Care Management Plus
    Using Technology to Improve Outpatient Care for Older Adults
  • Description of the Model: Care Management Plus
  • Illustration: Care Management Plus Model
  • Measuring the Success of Care Management Plus
  • The National Search for Quality Health Care Finds Care Management Plus
  • Tracking Care Over Time Helps Avoid Serious Disability
• Model 3: Senior Health & Wellness Clinic
  Managing Care of Older Patients in the Clinic by Fostering Team Care
  • Model 3: Senior Health & Wellness Clinic
    Managing Care of Older Patients in the Clinic by Fostering Team Care
  • Senior Health and Wellness Center: Total Care Under One Roof
  • Team Care Approach at Senior Health and Wellness Center
  • Measuring the Success of Senior Health and Wellness Clinic
  • Illustration: Senior Health and Wellness Clinic
  • Customizing Team Care to Work Locally
  • From Clinic Volunteer to Clinic Patient, But Always a Member of the Team
• Model 4: Virtual Integrated Practice
  Implementing Team Care Across Practices and Virtually
  • Model 4: Virtual Integrated Practice
    Implementing Team Care Across Practices and Virtually
  • Virtual Integrated Practice: The Community Response
  • Measuring the Success of Virtual Integrated Practice
  • Illustration: Virtual Integrated Practice Model
  • Building Community Capacity
  • VIP: A Seamless System of Resources
• Senior Resource Team
  Important Role Foundations Play in Taking Risk
• Looking Toward the Future of Team Care

Featured Initiative:

Care Transitions Model

Improving Transitions Across Sites of Geriatric Care

To address the problems of uncoordinated and fragmented care around the period of hospitalization, the Foundation awarded the University of Colorado Health Sciences Center, Denver, Colorado, a five-year grant of $1,207,404 in 2000 to develop the Care Transitions Intervention. Dr. Eric Coleman served as principal investigator of this project. Dr. Coleman is a Robert Wood Johnson Clinical Scholar and a Beeson Scholar. He has served on the American Geriatrics Society health care systems committee and has worked with federal policy makers through convenings such as those of the National Health Policy Forum.

Eric Coleman, MD, MPH
Principal Investigator,
Care Transitions
University of Colorado

Older patients with serious or multiple chronic illnesses are at risk for suffering new health problems or worsening of their existing conditions following a hospital stay. For example, a patient with diabetes who has received confusing or possibly conflicting information about a change in his medication regimen while in the hospital may wind up with uncontrolled blood sugar levels.

Older patients with complicated health problems often see numerous health care providers, a number that increases if treatment in a hospital becomes necessary. The patient may be treated by a primary care physician and various specialists in their medical offices, a hospitalist physician and nursing team in the hospital, a different physician and nursing team during a stay in a skilled nursing facility, and a visiting nurse in the home. Care can become fragmented when these providers work independently of one another or, worse, at cross purposes. Even when each health care provider delivers high quality care, the result can be substandard care if their efforts are not coordinated. "If you're selling umbrellas, you have to figure out how to make it rain. We make it rain by reshaping the health care environment to embrace these team care models."Eric Coleman, MD, MPH
Principal Investigator,
Care Transitions Shorter hospital stays and inefficient systems for transferring medical information from one health care site to another often place a burden on patients and their families to navigate the complex health care system. Yet patients and their families rarely receive adequate information and preparation to manage and coordinate care after a hospital stay.

Lack of coordination on the part of health care providers and inadequate preparation of patients increases the risk for medication errors and health complications. This leads to avoidable readmissions to the hospital, leading to greater health care costs. National 30-day readmission rates among older Medicare beneficiaries range from 15 to 25 percent.^12,13

Medication errors are of particular concern. A study by Dr. Eric Coleman and colleagues found that 14 percent of elderly patients admitted to the hospital experienced one or more discrepancies between their prehospital medication regimen, posthospital medication regimen, and what the patient reported actually taking.¹⁴ Factors involving patients, such as misunderstandings and other reasons for not complying with the regimen, contributed to about half of the medication errors. The other half of the errors were attributable to prescribers or the broader health care system. Medication discrepancies led to a greater number of hospital readmissions within 30 days.

Dr. Eric Coleman and his colleagues at the University of Colorado Health Sciences Center developed the Care Transitions Intervention team care model (www.caretransitions.org) to address these problems. The Care Transitions Intervention focuses on providing support and education for the patient and family caregiver. Interdisciplinary team care generally does not extend beyond the walls of a given institution. The only common thread moving across all sites of care is the patient and the caregiver, who become de facto care coordinators.

"We need to fix the broken health care system where providers don't talk to each other," says Dr. Coleman. "But in the meantime, we need to support patients and families in their self-management role." Placing the older adult patient (and caregiver) at the center of the interdisciplinary team in no way abdicates the responsibilities of the health care professionals. This arrangement encourages greater accountability for ensuring that the essential steps that need to take place before and after transfer are executed.
Next: The Four Pillars of Care Transitions ›
12- Coleman EA, Min S, Chomiak A, Kramer AM. Post-hospital care transitions: patterns, complications, and risk identification. Health Serv Res. 2004;39:1449-1465.
13- Centers for Medicare and Medicaid Services. Medicare Quality Monitoring System. 2006. http://www.cms.hhs.gov/QualityInitiatives GenInfo/15_MQMS.asp.
14- Coleman EA, Smith JD, Raha D, Min S. Posthospital medication discrepancies. Arch Intern Med. 2005;165:1842-1847.