Care Transitions – Project 2.b.i.v


The purpose of the Care Transitions project was to provide a 30-day supported transition period after a hospitalization to ensure discharge directions were understood and implemented by the patients in an effort to reduce occurrence of hospital readmissions. To meet this objective, CCN leveraged the Eric Coleman model of Care Transitions to create a standardized approach which focused on four pillars of support: Medication management, patient education on signs and symptoms, follow-up care, and personal health record.

Using  these pillars, CCN and partners developed and implemented community-wide standards of patient care for the initial 30-days following a discharge. A Health Coach role was created and standardized across the region, and a standardized method for tracking Health Coach services was implemented to address the gap among organizations who previously did not have an electronic health record (EHR) system.

Download Project Evaluation White Paper for Care Transitions – Project 2.b.i.v.