Organizations interested in adopting the model are encouraged to visit www.caretransitions.org to request an introductory DVD, download the manual, review the tools for Transition Coaches and patients/family caregivers, and to learn more about the model (all are available at no cost). Those organizations that are interested in pursuing adoption are then encouraged to first secure the support of senior leadership and begin to identify who will perform the role of the Transition Coach(es). Once this has been determined, organizations are encouraged to contact the Care Transitions InterventionSM via www.caretransitions.org.

The Care Transitions InterventionSM started with an APN with self-management training as one of its initial coaches. The program also recruited home health care RNs, who are comfortable working autonomously and in patients’ homes, and RNs who had worked in disability, who were used to moving people from health care institutions to the home.

Advance Practice Nurses, Registered Nurses, and Social Workers have all successfully performed the role of the Transitions Coach. Social Workers have generally benefited from having real time access to pharmacy expertise.

The Care Transitions Program offers trainings at several levels and has expanded training options to be able to reach out to both larger and smaller organizations. Trainings generally last a day and a half and are highly interactive and case based. One option is a simulation lab where coach trainees receive in-depth instructor attention, learn from standardized patient actors, and their experiences are recorded onto DVDs to enhance present and future learning opportunities. The Care Transitions Program is also currently developing a web based learning platform to provide online training.

The process of selecting patients for The Care Transitions InterventionSM varies by organization. Some model adoptees send Transition Coaches into the hospital to identify patients who meet the criteria (described on the Overview page) and could benefit from the intervention. Other organizations educate hospital discharge planners on the patient selection criteria and have the discharge planners identify patients; in many of these cases, the discharge planners confer with the Coaches by phone.

To date over 150 of the nation’s leading health care organizations have adopted the model. There has been exceptional diversity among the care settings that have adopted the model. In fact, no two organizations have been identical. The model has been implemented in rural populations, low literacy populations, African-American and Hispanic populations, and in high performing as well as low performing markets.

The California HealthCare Foundation provided funding for ten sites in the state of California to implement The Care Transitions InterventionSM. These organizations intend to use different types of individuals as Transition Coaches, including nurses, social workers and nursing students.

In addition, the Community Health Foundation of Western and Central New York funded 13 teams in the greater upstate New York area to implement the model (this has also filled its slots and will conclude in October 2008.

The Care Transitions Intervention has broad appeal for replication, due to relatively low intensity and low cost of implementing the model. The Care Transitions Intervention aligns with NQF Priorities and with many organizations’ strategic goals:

• Capitated programs: decrease costs due to decreased hospital readmissions
• Home Health Care agencies: obtain a higher volume of referrals by differentiating themselves from competitors
• Large ambulatory clinics: to improve efficiency or meet PCMH standards
• Community agencies: supports mission to keep people in the community by increasing self management skills
• Hospitals: Improve community image; meet Joint Commission standards; reduce diversion and create greater capacity for higher revenue patients; increase market share as a preferred provider; prepare for likely changes in readmission reimbursement