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Care Transitions Model:

Measuring the Success of Care Transitions

With the Care Transitions Intervention model patient health and well-being are improved and the health care system derives cost savings from reduced readmission to the hospital. Both patients and health care providers report satisfaction with the program.

These results were demonstrated in studies conducted by Dr. Coleman and his colleagues. In one study, performed in 2004, hospitalized patients who received the Care Transitions Intervention were approximately half as likely to return to the hospital as those who did not receive the intervention.15 In a study from 2006, which was funded by the Hartford Foundation, patients receiving the Care Transitions Intervention also had lower rehospitalization rates.16 This study also found that hospital costs were lower for patients with care transition coaches. The investigators estimated that the hospital, health plan, or clinic which employs the coach can realize annual net cost savings of $295,594 across 350 patients. “Creating the Care Transitions Intervention model required creativity and innovation; developing the avenues for dissemination and widespread adoption necessitates a different skill set, but just as much innovation.”Eric Coleman, MD, MPH
Principal Investigator,
Care Transitions
Dr. Coleman's team has also shown that patients who were assisted by care transitions coaches had greater knowledge and skills regarding their illness.17 They understood how to manage their medications and they confidently knew what was required of them during the transition period. The continuity of the coaching relationship fostered a sense of caring, safety, and predictability about the transition, which contributed to greater patient investment in the program.
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15- Coleman EA , Smith JD, Frank JC, Min SJ, Parry C, Kramer A. Preparing patients and caregivers to participate in care delivered across settings: the care transitions intervention. J Am Geriatr Soc. 2004;52:1817-1825.
16- Coleman EA , Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Intern Med. 2006;166:1822-1828.
17- Parry C, Kramer H, Coleman EA . A qualitative exploration of a patient-centered coaching intervention to improve care transitions in chronically ill older adults. Home Health Serv Q. 2006;25(3-4):39-53.