Get Started Implementing the Care Transitions Intervention in Your Community

This provider toolkit outlines the Washington State Department of Social & Health Services' Care Transitions Intervention, a four-week program in which patients and their families receive self-empowerment training to improve care transitions. The authors report results showing that enrolled patients were significantly less likely to be readmitted to the hospital and that these gains held for five months post-hospitalization. A trained Transitions Coach implements this approach; the four essential elements of the program are: 1) medication self-management; 2) use of a patient-centered health record; 3) timely follow-up post-discharge; and 4) patient recognition and response to worsening symptoms.