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.
Next: Moving the Model from Two Sites to 100 ›
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.