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case management, care transitions, leadership, model sustainability, transitions of care, translation into practice



  1. Parrish, Monique M. DrPH, MPH, MSSW
  2. O'Malley, Kate MS, RN, GNP
  3. Adams, Rachel I. BS
  4. Adams, Sara R. MPH
  5. Coleman, Eric A. MD, MPH


Purpose: During care transitions, the movement of patients from one healthcare practitioner or setting to another, patients are vulnerable to serious lapses in the quality and safety of their medical care. The Care Transitions Intervention (CTI), a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from the acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self-management needs are met, was implemented in 10 hospital-community-based partnership sites in California over a 12-month period. Five of the partnerships were hospital-led sites, and 5 were county-led sites. The primary goal of the project was to identify factors that promote sustainability of the intervention by (1) assessing features of each site's implementation and the site's likelihood of continuing the program; (2) soliciting feedback from the sites; and (3) analyzing site and patient characteristic data and data from the CTI measurement instruments (the 3-item Care Transition Measure [CTM-3] and the Patient Activation Assessment [PAA] tool).


Primary practice setting(s): The CTI was implemented in 10 California hospital and community-based organizations that received training and technical support to implement the intervention.


Findings: Presence of leadership support was determined to be the critical factor for sites reporting interest in and capacity for long-term support of the CTI. Sites identified engaging hospital- and community-based leaders, providing additional transition coach training, and the assigning of consistent and dedicated (funded) transition coaches as valuable lessons learned. Key findings from the measurement instruments indicate that future CTI implementations should focus on medication management, patients with cardiovascular conditions and diabetes, patients older than 85 years, and African American and Latino patients. Mean PAA scores were moderately higher for patients from hospital-led sites than for patients from county-led sites and moderately higher for patients from sites with full plans for continuation than for patients from sites with partial or minor plans to continue the CTI.


Implications for case management practice: This implementation of the CTI, with its flexible design responsive to the diverse needs of patients, hospitals, and community organizations, provides a host of real-world lessons on how to improve and sustain effective patient transitions between care settings. Healthcare systems interested in improving care transitions have a compelling reason to explore the viability of implementing the intervention with attention to developing or addressing the following: strong care transitions leadership; collaborative hospital-community partnerships; the particular needs of diverse communities; patient-level medication reconciliation and management; and tailoring the model to the unique needs of patients with cardiovascular conditions and diabetes.