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The term "care transitions" refers to the movement of individuals between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. A position statement from the American Geriatrics Society defines transitional care as a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.
Nearly one in five Medicare patients discharged from a hospital, or approximately 2.6 million beneficiaries, is readmitted within 30 days, at a cost of over $26 billion every year. Hospitals have traditionally served as the focal point. The goals of care transition programs are to improve transitions from the inpatient hospital setting to other care settings, to improve quality of care, to reduce readmissions for high risk individuals, and to document measurable savings to the Medicare program.
Many Area Agencies on Aging (AAAs) are involved in care transitions projects in partnership with their local hospitals or healthcare systems. Currently, all are using the Coleman Care Transitions Model that is based on the four pillars of 1) medication self-management, 2) patient-centered record, 3) follow-up with the healthcare practitioner, and 4) knowledge of red flags. Certification as a Care Transitions Coach in the Coleman Model is required.
