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Hall KK, Shoemaker-Hunt S, Hoffman L, et al. Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2020 Mar.
Tara Earl , Ph.D., M.S.W., Nicole Katapodis , M.P.H., and Stephanie Schneiderman , M.P.P.
As patients prepare to move from the hospital to other settings, failing to make adequate discharge arrangements can lead to costly and unnecessary hospital readmissions, preventable adverse events, and drug-related errors. 1 – 12 For example, in 2008 nearly one-fifth of Medicare beneficiaries had an unplanned hospital readmission within 30 days of discharge, which together totaled nearly $15 billion; more than 75 percent of those readmissions (costing about $12 billion) were potentially preventable. 13
Ensuring safe and seamless transitions starts well before hospital discharge. 14 Successful transitioning of patients from the hospital to other care settings is a dynamic, multifaceted process in which healthcare systems, hospitals, providers, patients, and their families share responsibility. Models or interventions such as Better Outcomes for Older Adults (BOOST), the Care Transitions Intervention (CTI), and the Transitional Care Model (TCM) were developed with the intention of improving transitions across the continuum of care. These models appear to be especially beneficial for high-risk and older adult populations, who are often hospitalized; move frequently across care settings; and experience high rates of post-discharge complications, readmissions, or morbidity and mortality. 10 , 15 – 18
Initial literature searches for patient safety practices (PSPs) in the harm area of care transitions were focused on systematic reviews and guidelines. Results of these searches were reviewed by task leads for the harm areas to identify PSPs, iterate on searches as needed, and refine lists of PSPs to concentrate on. Next, the project Technical Expert Panel and Advisory Group were engaged via a survey to prioritize PSPs for inclusion in the report. These survey results, along with refined recommendations for PSP inclusion, were submitted to the Agency for Healthcare Research and Quality (AHRQ) for review. After several rounds of review with AHRQ, one care transition PSP was selected for this harm area: use of multi-element models to improve care transitions.
This review includes articles published from 2004 to 2017 that focus on transitional care and patient safety. It highlights three evidence-based multi-element care transition models that were developed to reduce harm and improve transitions as patients move from one setting to another, specifically from hospital to home. The three models are Better Outcomes for Older adults through Safe Transitions (BOOST), the Care Transitions Intervention (CTI), and the Transitional Care Model (TCM). The definition of this practice area, along with key elements recommended by the National Transitions of Care Coalition (NTCC), are to help shape the thinking about how best to improve transitional care practices. An overview of each of the three models and a discussion of the current evidence are presented in this chapter. The review concludes by identifying potential gaps or challenges and future directions.
Transitioning patients from one setting to another is a particularly vulnerable time. Safety lapses can result in negative clinical outcomes, 1 – 4 preventable adverse events, 5 – 9 and avoidable hospital readmissions. 10 , 12 The Joint Commission defines transitions of care as “the movement of patients between health care practitioners, settings, and home, as their conditions and care needs change.” 19 In light of consequences that hospitals can face when patients return within 30 to 60 days of discharge, 20 , 21 this review focuses specifically on evidence related to transitions from hospitals to ambulatory care settings, by highlighting three multi-element models as indicated in the Key Findings box.
Implementing BOOST contributes to reductions of 30-day re-hospitalization rates, and using the assessment tool accurately predicts 90 percent of readmissions.
Medication Management: Ensuring the safe use of medications by patients and their families based on patients’ plans of care.
Transition Planning: Creating a plan/process that facilitates the safe transition of patients from one level of care to another, including home or from one practitioner to another.
Patient/Family Engagement and Education: Educating and counseling patients and families to enhance their active participation in their own care, including informed decision making.
Communicating and Transferring Information: Sharing of important care information among patient, family, caregiver, and healthcare providers in a timely and effective manner.
Follow-Up Care: Facilitating the safe transition of patients from one level of care or provider to another through effective follow-up care activities.
Healthcare Provider Engagement: Demonstrating ownership, responsibility, and accountability for the care of the patient and family/caregiver at all times.
Shared Accountability Across Providers and Organizations: Enhancing the transition of care process through accountability for care of the patient by both the healthcare provider (or organization) transitioning, and the one receiving the patient.
Table 15.1 describes how the essential elements for safe and seamless transitions are represented across the three models.
Essential Elements of Safe and Seamless Care Transitions for Three Multi-Element Models.
The general methodology used across the project is available in the Methods chapter of this report. Below, is a summary of the approach that was used to search for literature and the review methods specific to the practice area.
Two databases (CINAHL ® and MEDLINE ® ) were scanned for literature specific to the three models by using “BOOST,” “Better Outcomes for Older Adults Through Safe Transitions,” “CTI,” “Care Transitions Intervention Model,” “Transitional Care Model,” and “TCM.” Then we expanded the search by including “care transitions,” “transitional care,” “patient safety,” “follow up,” and “health.” MeSH terms included “patient discharge,” “patient transfer,” “transfer,” “discharge,” “patient handoff,” “discharge planning,” “teach back models,” “health,” “ambulatory,” and terms related to the seven essential elements previously discussed. The search string also included different healthcare settings, such as “hospitals,” “inpatient,” “long-term care,” “nursing home,” and “skilled nursing facility.” To make sure we identified the most relevant articles, reference lists of selected articles were screened and additional articles were reviewed. A developer of each model was consulted to confirm that all known model-specific publications were identified.
In all, 157 de-duplicated publications were identified, and 115 full-text articles were considered eligible for further review based on whether they were published in English, explicitly focused on a transition from one care setting to another, included one of the three care transition models, and addressed ways to improve patient safety. Priority was given to intervention studies that centered on one of the three models, foundational or seminal reports, and research studies with quantitative and/or qualitative methods. Records were excluded if the focus was on children/pediatric care and/or if the publication was more of a commentary or editorial than a research study. Upon closer review, full-text articles were disqualified if they were deemed incomplete, insufficient, or “out of scope” by the review team. Out-of-scope articles referenced the care models but were primarily comprised of topics such as handoffs between providers, not from one care setting to another, or teach-back methods. As a result, 16 studies were selected for this review.
General methods for this report are described in the Methods section of the full report.
For this patient safety practice, a PRISMA flow diagram and evidence table, along with literature-search strategy and search-term details, are included in report appendixes A through C.
The next sections of this chapter present evidence from the 16 studies that we reviewed. These studies describe implementation activities that examined how implementing BOOST, CTI, and TCM have impacted the care transition process and influenced hospital readmission rates. The evidence in this section highlights intervention, prevalence, observational, and incidence studies that will inform the reader about key outcomes, and implementation strategies and resources for the three care transition models.
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Roy CL, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005;143(2):121–8. doi: 10.7326/0003-4819-143-2-200507190-00011. [PubMed : 16027454 ] [CrossRef]
Pippins JR, Gandhi TK, Hamann C, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414–22. doi: 10.1007/s11606-008-0687-9. [PMC free article : PMC2518028 ] [PubMed : 18563493 ] [CrossRef]
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Moore C, Wisnivesky J, Williams S, et al. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646–51. doi: 10.1046/j.1525-1497.2003.20722.x. [PMC free article : PMC1494907 ] [PubMed : 12911647 ] [CrossRef]
Wenger NS, Young RT. Quality indicators for continuity and coordination of care in vulnerable elders. J Am Geriatr Soc. 2007;55: Suppl 2:S285–92. doi: 10.1111/j.1532-5415.2007.01334.x. [PubMed : 17910549 ] [CrossRef]
Kripalani S, Roumie CL, Dalal AK, et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: A randomized trial. Ann Intern Med. 2012;157(1):1–10. doi: 10.7326/0003-4819-157-1-201207030-00003. [PMC free article : PMC3575734 ] [PubMed : 22751755 ] [CrossRef]
Li J, Young R, Williams MV. Optimizing transitions of care to reduce rehospitalizations. Cleve Clin J Med. 2014;81(5):312–20. doi: 10.3949/ccjm.81a.13106. [PubMed : 24789590 ] [CrossRef]
Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161–7. doi: 10.7326/0003-4819-138-3-200302040-00007. [PubMed : 12558354 ] [CrossRef]
Enderlin CA, McLeskey N, Rooker JL, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs. 2013;34(1):47–52. doi: 10.1016/j.gerinurse.2012.08.003. [PubMed : 23122908 ] [CrossRef]
Glintborg B, Andersen SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Health Care. 2007;16(1):34–9. doi: 10.1136/qshc.2006.019828. [PMC free article : PMC2464919 ] [PubMed : 17301202 ] [CrossRef]
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Medicare Payment Advisory Comission. Report to the congress: Reforming the delivery system.Washington, DC: Medicare Payment Advisory Commission 2008. http://www .medpac.gov /docs/default-source /reports/Jun08_EntireReport.pdf.
Spehar A, Campbell R, Cherrie C, et al. Seamless Care: Safe Patient Transitions From Hospital to Home. In: Henriksen K, Battles J, Marks E, editors. Advances in Patient Safety: From Research to Implementation (Volume 1: Research Findings). Rockville, MD: Agency for Healthcare Research and Quality; 2005. https://www .ncbi.nlm .nih.gov/books/NBK20459/. [PubMed : 21249792 ]
Kripalani S, Theobald CN, Anctil B, et al. Reducing hospital readmission rates: Current strategies and future directions. Annu Rev Med. 2014;65:471–85. doi: 10.1146/annurev-med-022613-090415. [PMC free article : PMC4104507 ] [PubMed : 24160939 ] [CrossRef]
Clarfield AM, Bergman H, Kane R. Fragmentation of care for frail older people--an international problem. Experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc. 2001;49(12):1714–21. doi: 10.1046/j.1532-5415.2001.49285.x. [PubMed : 11844008 ] [CrossRef]
Parry C, Coleman E. Active roles for older adults in navigating care transitions: Lessons learned from the care transitions intervention. Open Longev Sci. 2010;4. doi: 10.2174/1876326X01004010043. [CrossRef]
Boling PA. Care transitions and home health care. Clin Geriatr Med. 2009;25(1):135–48, viii. doi: 10.1016/j.cger.2008.11.005. [PubMed : 19217498 ] [CrossRef]
McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796–803. doi: 10.1161/circulationaha.114.010270. [PMC free article : PMC4439931 ] [PubMed : 25986448 ] [CrossRef]
Zuckerman RB, Sheingold SH, Orav EJ, et al. Readmissions, observation, and the hospital readmissions reduction program. NEJM. 2016;374(16):1543–51. doi: 10.1056/NEJMsa1513024. [PubMed : 26910198 ] [CrossRef]
Project BOOST is a multicentered quality improvement (QI) transitional care program created in 2008 by the Society of Hospital Medicine to improve care for patients as they transition from the hospital to home. 1 The objective is to reduce 30-day readmission rates, improve provider workflow, and reduce medication-related errors. The model involves tools and resources to identify and manage patients who are at high risk for readmissions, with a particular focus on older adults. The contents of the BOOST Toolkit are shown in the box on this page.
When hospitals adopt this model they can tailor components to align with their unique needs, priorities, available resources, and culture. There is a toolkit that includes resources to address areas of the discharge process that are predisposed to result in adverse events. 2 Implementation outcomes (e.g., organizational change, reduced hospital readmissions) are estimated for 12 and 24 months post-discharge. 3 After the model is adopted, the hospital becomes part of a QI collaborative network through which they can communicate with and learn from other BOOST members around the country. Additionally, a BOOST Data Center allows users to store and benchmark data against control units and other providers.
BOOST is intended for use by all clinicians involved in the hospital discharge process (physicians, nurses, case managers, social workers), with a core team consisting of a team leader (nurse, case manager, social worker, or physician), QI facilitator, project manager, process owners (frontline staff involved in providing safe, effective care transitions in the hospital, including pharmacy, nursing, and case management staff), and information technology experts.
Comprehensive Intervention—The BOOST toolkit, which is used by hospitals to identify patients at high risk for readmissions, contains material for comprehensive intervention.
BOOST Implementation Guide—Provides detailed implementation guidance for hospitals.Individual Physician Mentoring—One year of mentorship by external physicians to provide implementation technical assistance to implementation teams at each participating hospital.
BOOST Collaborative—A peer-to-peer network of hospitals that are able to share resources via a listserv, regularly scheduled and ad hoc teleconferences, and other web-based platforms.
The Centers for Medicare & Medicaid Services (CMS) Hospital Readmission Reduction Program (HRRP) reduces payments to hospitals that have excessive 30-day readmissions for six diagnoses. This program applied initially to Medicare beneficiaries and, as of 2019, applies to Medicaid beneficiaries as well. The HRRP has increased attention on readmissions and length of hospital stay. In 2013, Hansen et al. evaluated the effect of BOOST on Medicare beneficiaries’ readmission rates and length of stay in a sample of 11 hospitals of varying size, academic affiliation, and location. 1 They found that BOOST was associated with a 3 percent decrease in 30-day readmissions (p=.010) after 12 months of implementation. The length of stay did not change significantly.
A qualitative study by Williams et al. (2014) sought to identify factors that contributed to how programs could be implemented to enhance collaboration across care settings, reduce hospital readmissions, and achieve optimal implementation of Project BOOST. The design involved an initial cohort of 6 pilot hospitals and a subsequent cohort of 24 hospitals of various academic affiliations, locations, and bed sizes. Based on qualitative findings from the first cohort, investigators added interactive exercise sessions in kickoff trainings, continued education via webinars, and increased mentoring calls, which they anticipated would lead to more complete implementation of BOOST in the second cohort. The individual mentoring component of BOOST was also refined for the second cohort. Qualitative analysis of the first cohort of hospitals included examining BOOST enrollment applications, examining the project listserv, and scripted telephone interviews with each site. Evaluation of BOOST implementation in the second cohort of hospitals occurred via mid-year and end-year surveys. By looking across the two cohorts, the investigators reported being able to better understand how the model can be implemented to enhance collaboration, as well as identifying important facilitators and barriers to implementation. Implementation facilitators included having individual physician mentoring sessions; establishing goals, objectives, and expectations that were small in scale but realistically attainable; teamwork exercises; and active patient engagement practices. Barriers included inadequate understanding of the BOOST implementation process, lack of administrative support, lack of protected time or resources dedicated to BOOST, and insufficient front staff buy-in. 2 When Lee et al. (2016) looked at the BOOST patient risk assessment tool via retrospective chart reviews, their findings indicated that the tool successfully predicted 90 percent of readmissions for patients 65 years of age and over when they assessed for two or more risk factors for readmission, but the tool was 99-percent effective in assessing risk when one factor was used. Although the tool shows promise in predicting readmissions, the authors cautioned against the use of multiple risk factors, as it could decrease the predictive power of the tool. 4
To date, no studies have intentionally studied the costs or economic outcomes related to implementing BOOST to reduce readmissions.
Hansen LO, Greenwald JL, Budnitz T, et al. Project BOOST: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–7. doi: 10.1002/jhm.2054. [PubMed : 23873709 ] [CrossRef]
Williams MV, Li J, Hansen LO, et al. Project BOOST implementation: Lessons learned. South Med J. 2014;107(7):455–65. doi: 10.14423/smj.0000000000000140. [PubMed : 25010589 ] [CrossRef]
Coffey C, Greenwald J, Budnitz T, et al. Project BOOST implementation guide. Society of Hospital Medicine; 2013. https://www .hospitalmedicine .org/clinical-topics /care-transitions/.
Lee GA, Freedman D, Beddoes P, et al. Can we predict acute medical readmissions using the BOOST tool? A retrospective case note review. Acute Med. 2016;15(3):119–23. pmid: 27759745. [PubMed : 27759745 ]
Medication Self-Management: Patient/caregiver is knowledgeable about prescribed medication(s) and establishes a medication management process.
Dynamic Patient-Centered Health Record: Patient (with assistance from caregiver, if necessary) uses the Personal Health Record (PHR) to communicate with and consult about continuity-of-care providers from across different settings.
Primary Care and Specialist Follow-Up: Patient schedules and completes follow-up visits with the providers (i.e., primary care provider or specialist) and is empowered to actively participant throughout
Knowledge of Red Flags: Patients understand indicators for when their condition is worsening and know how to respond.
Dr. Eric Coleman developed the Care Transitions Intervention in 2002 to improve continuity of care across care settings and providers. CTI is a patient-centered, multi-component program that has since been implemented in hospitals across the country. 1 Developed based on input from patients and their caregivers, CTI aims to improve the efficiency and quality of care in the transition from hospital to home by providing patients with tools and support to navigate the healthcare system and effectively manage their health conditions. 1
CTI is a 4-week, low-cost, low-intensity self-management program designed to provide patients discharged from an acute care setting with skills, tools, and the support of a transition coach to ensure that their health and self-management needs are met. The intervention targets patients age 65 years and older, who often have acute or chronic health conditions such as congestive heart failure, chronic pulmonary disease, diabetes, stroke, hip fractures, pulmonary embolism, and deep vein thrombosis. 2
CTI begins when the patient is in the hospital. A Transitions Coach sets up a meeting to discuss the patient’s concerns and to engage the patient and family to begin participating in the program. Next, the Transitions Coach conducts a follow-up home visit and a series of three phone calls in order to help the patient increase self-management skills and attain personal goals, and to provide the patient and his or her family continuity across the transition. Transition coaches can be advanced practice nurses (APNs), registered nurses, social workers, student nurses, community workers, or trained volunteers. Since CTI is designed to help patients manage their care once they transition out of the hospital, no studies reported long-term participation.
CTI’s four pillars of care are shown in the box on this page. CTI relies on personal health records (PHRs), which document the patient’s medical history, medications and allergies, any red flags or warning signs; provide a structured checklist of critical activities that take place prior to discharge (instructions and dates of follow-up appointments); and provide space for the patient to record questions and concerns.
First, a CTI transitions coach meets with a patient in the hospital prior to discharge to establish rapport, introduce the PHR, and arrange a home visit within 72 hours after discharge. One of the main goals of the home visit is to reconcile all of the patient’s medications using the Medication Discrepancy Tool. During this time, the transitions coach also helps the patient understand the purpose, instructions for use, and potential side effects of each medication. If medication discrepancies are identified, the coach encourages the patient/caregiver to call the physician’s office or make an appointment in person. Next, the transitions coach and patient role-play effective communication strategies to teach the patient to clearly articulate his or her needs with providers. Another goal of the home visit is to help the patient recognize red flags or warning signs that the health condition may be worsening. The intervention is implemented in a short timeframe, only 4 weeks. The home visit takes place during the first week. For the next 3 weeks, the transitions coach continues to support the patient and his or her ability to effectively manage care. For instance, the coach calls once a week to help the patient continue to make and track progress. The coach asks patients if they received appropriate outpatient services, reminds them to share their PHR with their primary care provider or specialists, and supports their disease self-management activities.
CTI focuses on 30-, 90-, and 180-day readmissions. Readmission rates were reported in five reviewed studies about CTI, three clinical controlled trials and two randomized controlled trials. They addressed three different patient populations: Medicare Advantage beneficiaries, fee-for-service Medicare beneficiaries, and low-income patients. Intervention patients enrolled in Medicare Advantage plans who had 1 or more of 11 diagnoses (stroke, congestive heart failure, coronary artery disease, cardiac arrhythmias, chronic obstructive pulmonary disease, diabetes, spinal stenosis, hip fracture, peripheral vascular disease, deep vein thrombosis, and pulmonary embolism) had lower readmission rates than patients with these diagnoses for whom CTI was not applied in all three time periods: 30 days (8.3 vs. 11.9, p=.048), 90 days (16.7% vs. 22.5%, p=.04), and 180 days (8.6% vs. 13.9%, p=.046). 2 , 3 Among beneficiaries with original fee-for-service Medicare insurance and with the same conditions as the previous group, readmission rates were also lower for CTI patients than non-CTI patients at 30 days (6.8% vs. 16.7, p=.15%), 90 days (9.3% vs. 31%, p=.01), and 180 days (38.1% vs. 20.9%, p=.08). 4 , 5 Among low-income patients for whom CTI was implemented who had hypertension, stroke, diabetes, heart conditions, or dementia, and/or were taking four or more medications, readmission rates were generally lower than for those without CTI, but this difference was not statistically significant at 30 days (9.6% vs. 17.3%), 90 days (28.9% vs. 25%), and 180 days (32.7% vs. 36.5%). 6
Parrish et al. (2009) worked with five hospitals and five community sites to identify key factors for sustaining CTI. Based on feedback from hospitals, they found that engaged leadership support, a strong project champion, adequate training of the transition coaches, and dedicated CTI staff were integral to sustaining CTI. 7 Coleman et al. (2015) adapted CTI to better serve the needs of family caregivers in one non-profit acute care hospital that had 253 beds through addition of a Family Caregiver Activation Assessment Tool (FCAA). 8 Family caregivers, who participated using the FCCA tool, experienced a mean improvement in activation of 6 points on a 1–10 scale in relation to the four intervention pillars than caregivers who did not use the tool (p<.0001), and became more involved in successful care transitions.
Of the six CTI studies reviewed, four examined the cost or cost effectiveness of implementing CTI, which varies based on provider characteristics and benefits and salary structure. For instance, in 2002, for patients who resided in the same State, the annual cost for implementing CTI for patients receiving or eligible for Medicare Advantage was $74,310, compared to $68,830 for patients who were eligible for Medicare fee-for-service coverage. 2 , 4 The difference in implementation costs appear to be influenced by provider characteristics, benefits, and salary structure. For example, the salary of a transition coach could be $70,980 for an APN compared to $65,500 for a registered nurse. As part of their role, transition coaches receive a cell phone and pager ($650), mileage reimbursement ($2,500), and other supplies such as PHR forms ($180). Coleman et al. (2006) observed that implementing CTI was significantly more cost efficient than usual care when treating patients eligible for Medicare Advantage. For example, hospital costs for those who received CTI were $2,058, as compared to $2,456 for those who received usual care (p=.049) at 180 days post-discharge. 2 In 2014, Gardner et al. observed similar patterns. Their study reports that among Medicare beneficiaries, those for whom CTI was used had significantly lower healthcare utilization during the 180 days after hospital discharge, lower total health costs ($14,729 vs. $18,779, p=.03), and an average cost avoidance of $3,762 compared to the controls. 9
Parry C, Coleman EA, Smith JD, et al. The care transitions intervention: A patient-centered approach to ensuring effective transfers between sites of geriatric care. Home Health Care Serv Q. 2003;22(3):1–17. doi: 10.1300/J027v22n03_01. [PubMed : 14629081 ] [CrossRef]
Coleman EA, Parry C, Chalmers S, et al. The care transitions intervention: Results of a randomized controlled trial. Arch Intern Med. 2006;166(17):1822–8. doi: 10.1001/archinte.166.17.1822. [PubMed : 17000937 ] [CrossRef]
Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817–25. doi: 10.1111/j.1532-5415.2004.52504.x. [PubMed : 15507057 ] [CrossRef]
Parry C, Min SJ, Chugh A, et al. Further application of the care transitions intervention: Results of a randomized controlled trial conducted in a fee-for-service setting. Home Health Care Serv Q. 2009;28(2–3):84–99. doi: 10.1080/01621420903155924. [PubMed : 20182958 ] [CrossRef]
Voss R, Gardner R, Baier R, et al. The care transitions intervention: Translating from efficacy to effectiveness. Arch Intern Med. 2011;171(14):1232–7. doi: 10.1001/archinternmed.2011.278. [PubMed : 21788540 ] [CrossRef]
Ohuabunwa U, Jordan Q, Shah S, et al. Implementation of a care transitions model for low-income older adults: A high-risk, vulnerable population. J Am Geriatr Soc. 2013;61(6):987–92. doi: 10.1111/jgs.12276. [PubMed : 23711200 ] [CrossRef]
Parrish MM, O’Malley K, Adams RI, et al. Implementation of the care transitions intervention: Sustainability and lessons learned. Prof Case Manag. 2009;14(6):282–93; quiz 94–5. doi: 10.1097/NCM.0b013e3181c3d380. [PubMed : 19935345 ] [CrossRef]
Coleman EA, Roman SP, Hall KA, et al. Enhancing the care transitions intervention protocol to better address the needs of family caregivers. J Healthc Qual. 2015;37(1):2–11. doi: 10.1097/01.JHQ.0000460118.60567.fe. [PubMed : 26042372 ] [CrossRef]
Gardner R, Li Q, Baier RR, et al. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med. 2014;29(6):878–84. doi: 10.1007/s11606-014-2814-0. [PMC free article : PMC4026506 ] [PubMed : 24590737 ] [CrossRef]
Hansen LO, Greenwald JL, Budnitz T, et al. Project boost: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–7. doi: 10.1002/jhm.2054. [PubMed : 23873709 ] [CrossRef]
Hirschman KB, Shaid E, McCauley K, et al. Continuity of care: The transitional care model. Online J Issues Nurs. 2015;20(3):1. [PubMed : 26882510 ]
Lee GA, Freedman D, Beddoes P, et al. Can we predict acute medical readmissions using the BOOST tool? A retrospective case note review. Acute Med. 2016;15(3):119–23. pmid: 27759745. [PubMed : 27759745 ]
Developed in 1981 at the University of Pennsylvania’s School of Nursing by a team led by Dr. Mary Naylor, the Transitional Care Model is a nurse-led intervention designed to improve the outcomes of chronically ill older adults who transition from hospital to home 1 and are at risk of readmission based on the following factors: one or more chronic illnesses, more than one hospital visit within the last 6 months, multiple prescribed medications to treat multiple conditions (i.e., polypharmacy), and living alone. 2 , 3 The model is implemented through the use of individualized, multidisciplinary, evidence-based clinical protocols that help to prevent declines in health and to reduce 30–60 day hospital readmissions. 2 , 3 In addition to reducing rates of readmissions, TCM also aims to enable patients and their family caregivers to manage their conditions themselves. Although originally designed for older adults at risk of readmission, the model has been recently adapted and tested with other populations, including individuals who are eligible for Medicaid and patients with psychiatric diagnoses in addition to chronic and other comorbidities. 4 , 5
Patients who fit the criteria for the intervention meet with an advanced practice nurse either in the hospital prior to discharge or within 48 hours after discharge. The APN conducts home visits and telephone support, and is available 7 days a week through the length of the intervention (usually extending for 2 months after discharge). The APN uses the initial visit to assess the patient and develop a plan of care based on medical needs and patient values. Subsequently, the APN focuses on active engagement and education of patients and family caregivers. APNs educate patients about their health conditions and risks, including how to recognize and manage symptoms of worsening. They use home visits to monitor symptoms and do medication reconciliation. APNs serve as liaisons between patients/family caregivers and healthcare providers to ensure that followup visits are scheduled with primary or specialist providers after discharge from the hospital. APNs are available to accompany patients to these followup visits, if requested.
Rigorous evaluation of interventions of TCM and detailed case summaries developed by participating APNs have led to continued refinement of the model’s nine core components, shown in the box on this page.
A recent study compared TCM to augmented standard care (ASC) and resource nurse care in three hospitals that are part of a larger healthcare system. ASC included usual care plus cognitive screening within 24 hours of each patient’s index hospitalization and delirium assessment continuously during the hospital stay. In resource nurse care, resource nurses coached hospital nurses and provided direct care. Resource nurses completed training on management and transition of hospitalized cognitively impaired older adults and attended seminars on cognitive impairment throughout the study period. The TCM intervention group had lower hospital readmission rates at 30 days (6/66) than the ASC (15/66, p <0.001) and resource nurse care (14/71, p=0.06) groups.2
A pilot study by Solomon et al. (2014) found that adapting TCM for patients with psychiatric diagnoses added unique challenges. While the pilot used a psychiatric nurse practitioner and had a psychiatrist available for consult, patients had needs that could not be addressed in the existing program, primarily related to housing instability and relationship conflicts. The study team suggested adding a social worker and peer specialist as part of the care team in addition to the specialized nurse practitioner. 4
Naylor MD. Advancing high value transitional care: The central role of nursing and its leadership. Nurs Adm Q. 2012;36(2):115–26. doi: 10.1097/NAQ.0b013e31824a040b. [PubMed : 22407204 ] [CrossRef]
Naylor MD, Hirschman KB, Hanlon AL, et al. Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. J Comp Eff Res. 2014;3(3):245–57. doi: 10.2217/cer.14.14. [PMC free article : PMC4171127 ] [PubMed : 24969152 ] [CrossRef]
Hirschman KB, Shaid E, McCauley K, et al. Continuity of care: The transitional care model. Online J Issues Nurs. 2015;20(3):1. [PubMed : 26882510 ]
Solomon P, Hanrahan NP, Hurford M, et al. Lessons learned from implementing a pilot rct of transitional care model for individuals with serious mental illness. Arch Psychiatr Nurs. 2014;28(4):250–5. doi: 10.1016/j.apnu.2014.03.005. [PubMed : 25017558 ] [CrossRef]
Roper KL, Ballard J, Rankin W, et al. Systematic review of ambulatory transitional care management (TCM) visits on hospital 30-day readmission rates. Am J Med Qual. 2017;32(1):19–26. doi: 10.1177/1062860615615426. [PubMed : 26625898 ] [CrossRef]
Pauly MV, Hirschman KB, Hanlon AL, et al. Cost impact of the transitional care model for hospitalized cognitively impaired older adults. J Comp Eff Res. 2018;7(9):913–22. doi: 10.2217/cer-2018-0040. [PMC free article : PMC6219439 ] [PubMed : 30203668 ] [CrossRef]
No unintended negative consequences were reported in this review of studies that examined the use of BOOST.
No unintended negative consequences were reported in this review of studies that examined the use of CTI.
Within a population of serious mental illness, there is a lack of patient receptivity to the intervention. Additionally, many participants lacked basic needs such as housing. Without stable housing, it is difficult to focus on managing medical conditions. 1
The effect on re-hospitalizations dissipated after 90 days, which could potentially be attributed to the cognitive impairment many older adults face. 2
There was no improvement in functional status, including basic activities of daily living. 2
Length of hospital stay decreased in BOOST hospital units. 3
Primary care service utilization rates increased. 4
No unintended positive consequences were reported in this review of studies that examined the use of TCM.
We reviewed 16 studies targeting three care transition models that, collectively, create a synergy for using multiple elements in order to more effectively impede preventable harm to patients as they transition across care settings. All three models were designed to target and improve care for adults age 65 and older.
This section describes barriers to and facilitators of using the multi-element models BOOST, CTI, and TCM to improve care transitions.
Challenge of translating external QI content to a local setting 3
Sites being encouraged to implement Project BOOT with no funds or dedicated time to support the implementation efforts. 3 , 5
Limited data submission due to hospital implementation design (no geographic rollouts or simultaneous rollout on appropriate clinical floors due to limited resources). 3
Inadequate staff understanding of hospital’s current discharge process. 5
Insufficient executive leadership support. 5
Limited front-line staff buy-in. 5
Limited funding dedicated to the implementation of CTI. 6
Lack of dedicated transition coaches. 6
Insufficient executive leadership support. 6
Limited patient receptivity to TCM intervention. 1
Insufficient communication between providers and service coordinators. 1
Limited access to patient data due to lack of electronic health record interoperability between service facilities. 1
Intensive mentor engagement to assist with site accountability and implementation trouble-shooting. 3 , 5
High level of institutional leadership support. 3
Increased team engagement in reducing hospital admissions. 3
Presence of an effective project champion to lead the implementation effort. 3
Implementation of Project BOOST initially as a small project with specific goals. 5
Use of interdisciplinary teams to facilitate teamwork and collaboration. 5
Regular feedback from patients, physicians, and other involved in the project. 5
Presence of executive leadership support for CTI or presence of a CTI champion. 6
Dedicated transition coaches made available through specific funding allotment. 6
Strong project management leadership. 6
Frontline staff commitment to CTI. 6
Continuity of transition coach relationships across care settings. 7
Tailored care targeting specific patient populations. 1 , 2
High level of institutional leadership support. 2
High level of front-line staff buy-in. 2
The following resources were cited in our review of the evidence and can be used when implementing the three models.
Society of Hospital Medicine: Project BOOST Implementation Toolkit 4 , 3 provides a compilation of materials to help hospitals implement the intervention and optimize the discharge process at local institutions. Visit https://www.hospitalmedicine.org/clinical-topics/care-transitions to download the Project BOOST Implementation Toolkit.
The Care Transition Measure–15 8 , 9 is a 15-question care transition measure questionnaire to assess the quality of care transitions and focus on patient-centeredness for the purpose of performance improvement. Visit https://caretransitions.org/wp-content/uploads/2019/09/CTM-15.pdf to access the CTM–15 questionnaire.
The Care Transition Measure–3 8 , 9 is a 3-question care transition measure questionnaire to assess the quality of care transitions and focus on patient-centeredness for the purpose of performance improvement. Visit https://caretransitions.org/wp-content/uploads/2019/09/CTM-3.pdf to access the CTM–3 questionnaire.
The Family Caregiver Activation in Transitions (FCAT) Tool 8 , 9 is a tool designed to facilitate productive conversations between healthcare professionals and family caregivers during the discharge process. The tool can be administered by a health professional or self-administered by the caregivers at any point of transition of care. Visit https://caretransitions.org/wp-content/uploads/2019/09/Family-Caregiver-Activation-in-Transitions-FCAT-tool.pdf to download the Family Caregiver Activation in Transitions (FCAT) tool.
For instructions on how to implement the above tools, please visit The Care Transition Program website’s Tool and Resources page at https://caretransitions.org/all-tools-and-resources/.
TCM nurse-specific orientation and web-based modules 3 , 2 are available. The Foundations of Transitional Care seminar is an orientation designed for nurses and other team members reviewing evidence-based tools and strategies used for successful transitional care. There are also three TCM-specific modules, Understanding TCM Components and Tools, Applying TCM to Individual Patients, and Incorporating TCM in System Redesign, which focus on aspects of TCM implementation. For more information on these resources, please visit https://www.nursing.upenn.edu/ncth/resources/.
Across the three models, there are notable gaps with regard to implementation. For instance, while BOOST has been implemented in over 180 hospitals, more evidence is needed to determine its effectiveness, especially as it relates to implementing the model in care settings other than hospitals and to cost-related outcomes. 10 For CTI, although the evidence is rapidly advancing, given the prominent role of physicians, there is a need to assess their perspective and/or satisfaction regarding implemention. 8 More strategies are also needed to determine how best to incorporate patients and family caregivers voice and preferences into the CTI to further engage them 5 Since the majority of CTI studies have focused on Medicare fee-for-service or Medicare Advantage beneficiaries, the generalizability of the intervention beyond these populations should be explored. Despite advances in TCM research, gaps exist regarding the effectiveness of specific services that qualify under certain Current Procedural Terminology (CPT) codes. 11 TCM is an understudied approach, with only three studies identified that have utilized all the required elements for TCM service for Medicare’s billing code. 11 Current studies often lack a focus on the organizational contexts of various health systems that promote a successful transitional care strategy; therefore, future research should focus on TCM effectiveness across a variety of different settings.
The evidence for each of the models is still evolving. In this section we highlight considerations for future work. The hospitals that have implemented BOOST were described as being big urban academic medical centers that often have the infrastructure and resources to run large quality improvement projects. Future implementation efforts of BOOST should focus on examining its impact in smaller or rural hospital settings, where additional financial support for QI and data collection may be required. 12 Researchers also recommended that future studies assess the influence of using BOOST’s mentoring component as well as assessing the role of organizational content on the effectiveness of this model. 12 Researchers who studied CTI recommended more attention to factors such as medication management, patients with cardiovascular disease and diabetes, and patients older than 85 years who identified as African American or Latino, as the average profile of CTI patients was white women 76–85 years old. 6 Since researchers are starting to expand the use of TCM beyond older adults, examining the effectiveness of implementing this model for patients with lower socioeconomic status or lower incomes, and also patients with psychiatric conditions or disorders, would be beneficial to the field. Researchers should also consider examining the potential of implementing TCM to add value to emerging care delivery models, including patient-centered medical homes, accountable care organizations, community-based palliative care programs, and population health models.
Solomon P, Hanrahan NP, Hurford M, et al. Lessons learned from implementing a pilot rct of transitional care model for individuals with serious mental illness. Arch Psychiatr Nurs. 2014;28(4):250–5. doi: 10.1016/j.apnu.2014.03.005. [PubMed : 25017558 ] [CrossRef]
Naylor MD, Hirschman KB, Hanlon AL, et al. Comparison of evidence-based interventions on outcomes of hospitalized, cognitively impaired older adults. J Comp Eff Res. 2014;3(3):245–57. doi: 10.2217/cer.14.14. [PMC free article : PMC4171127 ] [PubMed : 24969152 ] [CrossRef]
Hansen LO, Young RS, Hinami K, et al. Interventions to reduce 30-day rehospitalization: A systematic review. Ann Intern Med. 2011;155(8):520–8. doi: 10.7326/0003-4819-155-8-201110180-00008. [PubMed : 22007045 ] [CrossRef]
Ohuabunwa U, Jordan Q, Shah S, et al. Implementation of a care transitions model for low-income older adults: A high-risk, vulnerable population. J Am Geriatr Soc. 2013;61(6):987–92. doi: 10.1111/jgs.12276. [PubMed : 23711200 ] [CrossRef]
Coleman EA, Roman SP, Hall KA, et al. Enhancing the care transitions intervention protocol to better address the needs of family caregivers. J Healthc Qual. 2015;37(1):2–11. doi: 10.1097/01.JHQ.0000460118.60567.fe. [PubMed : 26042372 ] [CrossRef]
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Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc. 2004;52(11):1817–25. doi: 10.1111/j.1532-5415.2004.52504.x. [PubMed : 15507057 ] [CrossRef]
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Enderlin CA, McLeskey N, Rooker JL, et al. Review of current conceptual models and frameworks to guide transitions of care in older adults. Geriatr Nurs. 2013;34(1):47–52. doi: 10.1016/j.gerinurse.2012.08.003. [PubMed : 23122908 ] [CrossRef]
Roper KL, Ballard J, Rankin W, et al. Systematic review of ambulatory transitional care management (TCM) visits on hospital 30-day readmission rates. Am J Med Qual. 2017;32(1):19–26. doi: 10.1177/1062860615615426. [PubMed : 26625898 ] [CrossRef]
Hansen LO, Greenwald JL, Budnitz T, et al. Project boost: Effectiveness of a multihospital effort to reduce rehospitalization. J Hosp Med. 2013;8(8):421–7. doi: 10.1002/jhm.2054. [PubMed : 23873709 ] [CrossRef]
Moving patients from one care setting to another can pose significant risk. Implementing transitional care models such as BOOST, CTI, and TCM, which place an emphasis on medication management, transition planning, patient/family engagement and education, communication and transferring information, follow-up care, healthcare provider engagement, and shared accountability across providers and organizations, is a patient safety practice that appears to have great potential. Evidence shows that implementing these models results in standardization in discharge protocol, ultimately leading to a decrease in hospital readmissions and an increase in associated cost savings. However, more diverse studies using these models are needed to establish a firm evidence base in a variety of care settings.
Studies focusing on model implementation in a variety of care settings, including rural hospitals, patient-centered medical homes, accountable care organizations, and community-based palliative care programs, would lead to stronger clinical evidence and improved implementation. Existing studies primarily focus on Medicare populations in large urban academic medical centers. Future research on implementation of these models in a variety of settings with diverse patient populations is critical for understanding opportunities and outcomes associated with multi-element models designed to improve transitional care.
Reviewers: Katharine Witgert, M.P.H., Maulik Joshi, Dr.P.H., and Susan Edgman-Levitan, B.H.S.
