Hospital-to-Home Transitions

Improving Transitions to Outpatient Care (C-TraIn)

We want hospitalized patients to make the smoothest transition to the best outpatient care for them. The Care Transitions Innovation (C-TraIn) does just that—through patient education, better care coordination, and access to outpatient care. Our goal is to improve quality and the patient’s experience while also reducing hospital re-admissions and post-hospital emergency department visits.

The transition home after a hospital stay represents a vulnerable time for many patients. In the hospital, health care providers administer medications, deliver treatments, take care of patients’ meals, and patients aren’t responsible to self-manage their illness. Discharge can feel like a ‘voltage drop’ – suddenly patients are responsible for maintaining their day-to-day health; arranging medical appointments; and managing their own medications, medical equipment, and transportation. Poor transitions care lead to adverse drug events, worsening illness, and avoidable emergency department visits or hospitalizations. Even the most carefully guided transitions can be challenging, especially for patients who are socio-economically disadvantaged and chronically ill.

C-TraIn targets the specific needs of uninsured and low-income publicly insured patients through:

  • Transitional Care Nurses – To link patients to care and provide teaching to allow patients to self-management complex health problems
  • Pharmacy consultation – To tailor medication regimens and assess and mitigate patients’ barriers to obtaining and taking their medications as prescribed.
  • Clinic and hospital linkages – To improve access and care coordination across settings which often function in siloes.
  • Monthly team meetings – To bring together a mix of multidisciplinary providers from across the care continuum with the goal of improving quality and integrating systems of care.

This intervention helps improve transitional care quality; reduce emergency department use and avoidable hospital re-admissions; and provide better access to more appropriate and cost-effective health care.

What Impact will this have?

C-TraIn was developed at OHSU starting in 2009. The Health Commons Grant has supported the expansion of the C-TraIn model to three Legacy hospitals; and funds Transitional Care Nurses, pharmacists, physician champions and a project manager. The grant also provides a forum to share best practices and lessons learned across Health Share of Oregon partner organizations. We’re focusing on change management, to ensure C-TraIn’s positive impact for patients.