Care Transitions Collaborative – Application for Participation
The Care Transitions Collaborative will support hospitals and their community partners in implementing the Care Transitions Intervention. The Care Transitions InterventionÒ was designed by Dr. Eric Coleman in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.
Key Aspects
The Care Transitions Model® is composed of the following components:
· A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition.
· A structured checklist of critical activities designed to empower patients before discharge from the hospital or nursing facility.
· A patient self-activation and management session with a Transitions Coach® in the hospital-designed to help patients and their caregivers understand and apply the first two elements and assert their role in managing transitions.
· Transitions Coach® follow-up visits in the home or a transitional care unit and accompanying phone calls designed to sustain the first three components and provide continuity across the transition.
Organizational Commitment
· Participate in the 1.5 day Care Transitions Intervention Training – April 12-13, 2012
· Participate in required pre-implementation activities
· Designate committed staff to implement the plan of action
· Allocate required resources to support program success
· Coordinate and align care transitions work with other activities aimed at reducing avoidable readmissions
· Plan to implement the Care Transitions Interventions® in April 2012
Collaborative Timeline
February 15, 2012 / Organizations submit applications*February/March 2012 / Organizations conduct required pre-implementation activities
April 2012 / Attend 1.5 day Care Transitions Intervention Training
April 2012 / Organizational implementation
May 2012 and ongoing / Participate in 3 follow-up Care Transitions Implementation conference calls
* All organizations are required to submit an application due to limited space. Each training sessions can accommodate up to 35 participants.
Care Transitions Intervention Training
Learning Collaborative – Application Form
q Our organization would like to participate in the Care Transitions Intervention Training - Learning Collaborative.
Organization Name: ______
City: ______State: ______
Primary Organizational Contact: ______
Email: ______Phone: ______
Anticipated Number of Participants: ______
CEO Signature: ______
Next Steps
Please complete this form and submit by February 15, 2012, to Rochelle Hayes, Institute for Clinical Systems Improvement. Email or fax 952-858-9675.
Note: A limited number of people can participate in the April Care Transitions Intervention Training. Once applications are received, the primary organizational contact will be notified about your participation status in mid February.
Additional Questions
Contact Rochelle Hayes at or phone 952-814-7098.