Care Transitions

Program Overview

Costly, avoidable hospital readmissions, a common occurrence in our region, are a symptom of a larger problem in our health care system. Effective transitional care, when a patient moves from one health care setting to another or to home, plays a pivotal role in health care systems for improving health outcomes, reducing hospital readmissions, and reducing avoidable health care spending. Many patients are not fully recovered with they leave the hospital, and a poor transition can lead to longer recovery times and stress for both patients and their caregivers. Coordinating transitional care services prevents medication errors, emergency room visits, and hospital readmissions, which results in lower health care costs and healthier, more satisfied patients

Top Metrics for Improvement

Metrics for this project are currently in draft form and are being updated by the Health Care Authority. The metrics under consideration include:

  • # of partners participating/# implementing each selected model
  • # partners trained by selected model; projected vs actual and cumulative
  • % partnering provider organizations sharing information via HIE to better coordinate care
  • VBP arrangement with payment/metrics to support adopted model
  • Outpatient Emergency Department Visits per 1000 Member Months
  • Percent Homeless (Narrow Definition)
  • Plan All-Cause Readmission Rates (30 Days)
  • Follow-up After Hospitalization for Mental Illness
  • Follow-up After Discharge from ED for Mental Health, ETOH or Other Drug Dependence
  • Inpatient Hospital Utilization


To improve safe, timely, effective, and coordinated care as patients move between settings. Increase patient safety and satisfaction, increase patient and family caregiver involvement and education, reduce preventable hospital readmissions, and reduce overall costs to the health care system.

CPAA will work directly with partnering providers to:
• Limit the time between patient discharge and follow-up appointments
• Reduce hospital readmissions
• Improve coordination between medical and community resources for high risk patients
• Expand admission screenings to identify high risk patients

Evidence-Based Approach

Transitional Care Model – The Transitional Care Model is designed to prevent health complications and readmissions of chronically ill, elderly hospital patients by providing them with comprehensive discharge planning and home follow-up, coordinated by a master’s-level “Transitional Care Nurse” who is trained in the care of people with chronic conditions.

The Care Transitions Intervention – The Care Transitions Intervention® is also known as the CTI®, the Skill Transfer ModelTM, the Coleman Transitions Intervention Model® and the Coleman Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.


You might be interested in the Transitional Care project if you want to assist patients in receiving appropriate transitional services to another facility or home. Health Care Providers and Community Based Social Service Organizations both play a critical role in this.

Transformation Timeline and Milestones

Project Work Group is working on:

1. Current state assessment
2. Identify Domain 1 strategies that support project
3. Finalize target populations and evidence-based approaches
4. Determine partnering providers
5. Complete implementation plans
6. Plan describing regional transition to fully-integrated managed care

Project Implementation in 2019, and scaling-up in 2020.

Social Determinants of Health and Care Transitions

Social determinants of health greatly affect transitional care. It’s much harder to stay healthy if you don’t have a home, a job, or nutritious food. It’s much harder to recover if you don’t have a primary care physician, transportation to follow-up appointments, or understand your medications. Success depends on improved communication between health care providers and community based organizations. Many times patients are admitted longer than medically necessary because there is no safe place to discharge them. CBOs play a critical role in closing the gap.

Project Area Contact

For more information, contact Kwabana Amoah-Fortson, Care Transitions Program Manager: