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Improving Care Transitions

When patients are ready to leave the hospital and return home—or move on to another care setting, like a rehabilitation facility—good communication and coordination are essential to a smooth transition. Research shows, however, that many patients do not receive clear instructions regarding their new medications or symptoms to watch for, or even the name of a person to contact with questions. For older patients and patients with chronic or complex conditions, improperly handled "care transitions" frequently result in readmission to the hospital. We recently spoke with Commonwealth Fund grantee Eric Coleman, M.D., associate professor of medicine at the University of Colorado Health Sciences Center, about how the Care Transitions Measure he designed not only improves the quality of transitions but also enables patients to become more engaged in their own care.

What is at the root of problems experienced by patients when they move from one care setting to another?
Dr. Eric Coleman: When a person moves from an acute care setting to home, or from a specialist office to a primary care office, it can involve multiple transitions—a whole string of handoffs. The problem is that the individual care team only sees one small slice of that, while the patient and family experience the whole episode.

When you ask patients and families about their experiences during care transitions, you hear about frustrations around information not making it from one care setting to the next: 'Why do I have to tell you my allergies again? I just told that other person two doors down.' What comes across even more strongly is that patients feel unprepared. It's partially a fear of the unknown, but they also don't feel prepared about their role—the self-care aspect. When they're in a hospital or nursing home, they're largely in a dependent role. Then, literally moments before discharge or transfer, suddenly the tables are turned and they're asked to assume a major role in their care. That, understandably, creates a lot of anxiety.

Even when patients try to do what's asked of them, if they run into problems or have questions, they can't reach the individuals who gave them the initial instructions. In addition, older adults—who may be overly respectful of their health care team—find their preferences are not taken into account. They don't feel like they have permission to speak up, to provide realistic insight when a care plan is not reasonable.

From the system side, we worry about conflicting information and other errors, particularly around medications. Although the term "error" implies you know the right plan of action when in fact, there may be multiple plans—each created without knowledge of the others. Thus, it probably makes more sense to talk about discrepancies that highlight when these distinct care plans are not aligned and to develop tools to help identify and resolve them.

What are the consequences of poorly coordinated care?
Coleman: The consequences include direct harm to patients. There are also financial implications. Patients in transition often seek care at high-intensity settings like emergency departments. There are also duplication and inefficiency costs: a clinician might reason, 'I know I'll never get the MRI results from that other provider, so I'll just repeat it.' It's also pretty clear that this area of care transitions is ripe-for-the-picking from a litigation standpoint, as we've already seen in the nursing home industry.

What is the purpose of the Care Transitions Measure, or CTM, you developed?
Coleman: We spent a lot of time early on deciding how to measure performance and care transitions. Do you ask hospital nurses if they did a good job preparing the patient for discharge? Clearly, only the patient would know if he or she was well-prepared. Across the transition, the patient and family caregivers are the only common denominator, which provides them with important and unique vantage points. We began by asking them to identify key areas for improving care and ensuring their needs were met. However, CTM was designed to be a measure of quality rather than satisfaction. We believed that patients' perceptions of quality would be closely linked to other important outcomes, and we demonstrated that patients with low CTM scores were significantly more likely to return to the emergency department or be readmitted to the hospital.

What did you find when you tested it with patients and providers?
Coleman: We've now tested it with well over a thousand individuals. It's clear patients have a story to tell, and CTM gives them an opportunity to tell it. Hospitals don't need to hire expensive consultants; they just have listen to what patients are telling them.

On the provider side, the general response has also been highly favorable—although, if you talk to individual clinicians, you quickly realize the problem of accountability is very pervasive. They may say, 'You can't hold physicians responsible for the handoff. That's the discharge planner's job or the social worker's job. It's everyone's job but mine.' At the system level, we've been working with health plans that have created pay-for-performance initiatives around CTM scores. The state of Maine has a bill before the legislature to mandate public hospitals to collect and publicly report their CTM scores. The World Health Organization has adopted it for use in a hospital quality initiative that will include 10 European countries, which will include translation beyond the current versions in English, Spanish, Finnish, and Hebrew.

What have you heard from patients about the kind of care transitions they've experienced?
Coleman: We health care providers truly have our work cut out for us. Across the country, we tend to see scores in low 70s [on a scale of 0 to 100]. Some of the better-performing health systems have scores in the low-to-mid-80s. We've yet to see scores in the 90s. With the support from The Commonwealth Fund, we have found that the scores are potentially modifiable when health systems concentrate efforts and resources.

How widely has CTM been adopted so far?
Coleman: We've received over 900 requests for permission to use the measure from 12 different countries. The nation's quality improvement organizations have become some of our best advocates and with the National Quality Forum's endorsement of the CTM in May 2006, we are hopeful that CMS or some other large entity will mandate the collection and public reporting of CTM scores. But, we've also been trying to demonstrate some successes on the local level. Peace Health [a health plan serving Alaska, Oregon, and Washington] plans to make collection of CTM scores routine within its system and provide ongoing feedback to providers.

What can hospitals do to address transitional care problems?
Coleman: There's a whole range of activities. Hospitals are already investing time and effort in medication reconciliation. We've been encouraging them to see this activity not just within the context of their facilities, but as an ongoing process. The job is not over just because the hospital has created a reconciled list—there's usually another opportunity to reconcile with the medications the patient has at home. There are also opportunities for hospitals to partner more closely with home care agencies and skilled nursing facilities by extending health care information technology to provide access to patient data to the care team at the next setting.

In addition to being a way that hospitals can help patients after they are discharged, does your work have longer-term implications?
Coleman: If you encourage older adults and their families to take a more active role, you can reduce a lot of the problems that occur during care transitions. The models we developed are designed to help support individuals in the moment, but they also provide the skills and tools they'll need down the road. This includes scripts of what to say when you can't get a follow-up appointment, or role-playing a conversation with your home care agency nurse. There's also a strong emphasis on having a personal health record to help overcome the information shortfall so patients become conduits of their own information. We invite people to learn more about the CTM as well as medication reconciliation and new models of care that involve coaching patients to assert a more active role during care transitions by visiting

November 2007

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