Transitional care

It includes logistical arrangements, education of the patient and family, and coordination among the health professionals involved in the transition.

[2] Healthcare utilization outcomes for patients experiencing poor transitional care include returning to the emergency room or being admitted to the hospital.

As healthcare expenditures rise at an unsustainable rate, there is increasing focus by patients, providers, and policymakers on restraining unnecessary resource utilization such as that incurred by preventable re-hospitalizations.

[5] Patient safety is increased by understanding and reinforcing health care providers' normal ability to bridge gaps.

Dr. Eric Coleman and his team at the University of Colorado at Denver and Health Sciences Center developed the CTM, as well as an intervention designed to improve patient outcomes during transitions.

[8] Nevertheless, it has been clearly demonstrated that longitudinal, personal continuity with a general practitioner reduces the need for out-of-hours services and acute admissions to hospital.

Although the coaching intervention occurs for the first 30 days following the transition, this approach has been shown to significantly reduce hospital readmission as far out as six months.

As part of the program, a Transitions Coach works directly with patients and family members for 30 days after discharge to help them understand and manage their complex postdischarge needs, ensuring continuity of care across settings.