Feb 022012

The following blog originally appeared on the Altarum Institute Health Policy Forum blog at www.healthpolicyforum.org on Tuesday, January 31, 2012. It is co-authored by Janice Lynch Schuster and Joanne Lynn.

“Care transitions” is the new buzzword in efforts to improve health, improve care and reduce costs. It seems that everyone is jumping on the bandwagon, implementing evidence-based solutions to problems in transitions, launching new programs and applying for funds totaling half a billion dollars from the Centers for Medicare & Medicaid Services.

In November, CMS announced the first seven communities to receive funding under its new Community-Based Care Transition Program: Atlanta; Akron/Canton; Chicago; Southwest Ohio; Southern Maine; Maricopa County, Arizona; and the Merrimack Valley of Massachusetts. Communities have developed remarkable partnerships. Atlanta is involving six urban area hospitals serving 10 counties. Southwest Ohio has a team that includes university and community hospitals, as well as a health council and information technology groups covering areas in Ohio, Kentucky, and Indiana. Merrimack will serve patients in 33 cities or towns in the region. In short, it is an impressive array of organizations that recognize that no single organization or entity can solve the problems of care transitions. It will, in fact, take a village, one that relies on many organizations and stakeholders to craft solutions that match their community’s preferences, resources and priorities.

For those who are young and relatively healthy, care transitions (i.e., hospital discharges) may not seem like a big deal. New mothers are discharged to follow up appointments with their OB/GYNs and pediatricians and usually can enlist new fathers and grandparents to help out with the baby during the early weeks. People who have an injury or a planned surgery will be discharged with instructions to follow up with their primary care doctors, take prescribed medications and maybe participate in physical therapy. For patients who are generally young and healthy, connecting the dots and mapping out a few weeks of a new routine may present a challenge, but it is easy enough to adjust to and figure out.

It is not so for frail elders and their caregivers—people who are over the age of 65, often over the age of 85, who have functional and cognitive impairments, who rely on others for activities of daily living and whose resources limit where they can go and whom they can see. Indeed, the transition often proves so difficult or ineffective that at least 20 percent of Medicare beneficiaries will be rehospitalized within 30 days of their initial discharge.

Poor discharge planning can be calamitous. A recent Health Affairs article chronicled the horror that ensued when a terminally ill patient was discharged home to hospice, only to arrive there with insufficient oxygen and no morphine. He died, suffocating, within 20 hours. The hospice nurse showed up afterward, apologized, and instructed the family on how to flush the morphine that they had finally received.

Many models have been developed and are being tested, hoping to prevent or eliminate the kinds of errors just described. Massachusetts’ Brian Jack, M.D., leads Project RED (Re-engineering Discharge), a hospital-based program that relies on enhanced staff training and a video avatar to help guide patients and families through discharge and follow-up. Colorado’s Eric Coleman, M.D., has developed an approach that emphasizes self-care capability and teaches four pillars to a good care transition. The Transitional Care Model relies on a specially trained advance practice nurse to work with families through the discharge process. Other models have been proposed and are being studied.

In our early work for Altarum Institute’s Center for Elder Care and Advanced Illness, we have found it useful to leverage changes in five areas in order to improve the design and implementation of effective care transitions quickly: medication reconciliation, patient activation, hospital discharge process, matching patients and services and information flow. In coming months, the CECAI staff will blog about each of these issues, sharing what we learned in the course of surveying the literature and experience to date. We expect that the movement will mature toward working on right-sizing the service array, dealing with advance care planning and providing feedback to earlier providers from later providers to enable improvement. We will keep watch for these and others.

It is intriguing that the solutions now underway rely so heavily on coalition building. Public health has long relied on this strategy to solve problems and promote social changes around other issues, such as smoking cessation, impaired driving, breastfeeding, the built environment and substance abuse. There are several definitions of what makes for a coalition; according to Frances Dunn Butterfoss, “coalitions are interorganizational, cooperative, and synergistic working alliances.”(1) Coalitions appear to go through three critical but nonlinear developmental phases: formation, maintenance and institutionalization.(2) As the newly developed CCTP programs launch, they will need to learn how to organize, lead and sustain an effective coalition. Perhaps those with experience and research can help.

The usual transition of an older person from hospital to home appears to entail multiple errors. Probably no other point in patient flow has so many errors and so great a tolerance for them. The current work on improving care transitions is long overdue and likely to make major improvements in cost and quality. The social capital that this work creates by pushing all parts of the care system to communicate and learn to work in a coordinated way is important; it could be the lynchpin of a new era of cooperative endeavors to build continuity into the fragmented care system.


1. Butterfoss, F. D., Goodman, R.M. & Wandersman. (1993). Community coalitions for prevention and health promotion. Health Education Research Theory and Practice, 8(3), 315–330
2. Osmond, J. Community coalition action theory as a framework for partnership development. Originally retrieved from mycalconnect.org/sacramento/download.aspx?id=10949 but which is now available from:

 Key words: care transitions, coalition building, frail elders, CCTP

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