Care Transitions Models

The U.S. Government defines the term “Care Transitions” as referring to the movement of patients from one health care provider or setting to another. For people with serious and complex illnesses, transitions in setting of care –for example from hospital to home or nursing home, or from facility to home – and community-based services– have been shown to be prone to errors.

The government, academic and healthcare sectors have responded to the needs of improving patient care transitions by engaging in research supporting the development of clinical and administrative models to address these challenges. For example, over the last two years an association, the National Transitions of Care Coalition (NTOCC) has joined groups of health plans, hospitals, health care companies, and government groups to provide publically available tips and tools for improving transitions of care.

There are four care transition models that have gained significant traction over the last several years:

  • BOOST™ – Better Outcomes for Older Adults through Safe Transitions
  • CTI™ – Care Transitions Intervention
  • Project RED™ – Re-Engineered Discharge
  • TCM™ – Transitional Care Model

Each of these models has been designed to address the issues inherent with complex care transitions, particularly with patients having significant comorbidities and/or requiring chronic care management. Activities common to these models include:

  • Improved Discharge activities from Inpatient Setting (though discharge from any point of care to another may be involved as well)
  • Enhanced patient and care giver education and instruction including specific instructions on chronic conditions and medications
  • Care coordination with primary care and medical home as well as all other care providers and community resources
  • Coaching and system navigation by care team to encourage self-management and engage patient in follow up appointments

Care Transition programs will become increasingly important as Accountable Care Organizations move towards implementation of Patient-Centered Medical Home (PCMH) models in response to mounting evidence of clinical improvement to patient health, reduction of costs, as well as Affordable Care Act regulatory dictates.