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Current initiatives focusing on coordination and continuity of care throughout episodes of illness.

Here are a collection of interventions aimed to improve care transitions and coordination between care settings. Click on the links below to learn about implementation processes for your organization.

Care Transitions Intervention (CTI)

Dr. Eric Coleman’s Care Transitions Intervention (CTI) is a 4-week program for patients with complex care needs who receive specic tools and are supported by a Transitions Coach®, and learn self-management skills to ensure their needs are met during the transition from hospital to home.

Visit CTI’s website

Transitional Care Model (TCM)

Mary D. Naylor’s The Transitional Care Model (TCM) provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions.

Visit the Transitional Care website

Better Outcomes for Older Adults through Safe Transitions (BOOST)

Project BOOST is a National initiative led by the Society of Hospital Medicine and guided by multidisciplinary leaders to improve the care of patients as they transition from hospital to home.

Learn more about BOOST

Re-engineered Discharge (RED): ProjectRED

Project RED is an evidence-based project from AHRQ grantee Brian Jack, M.D., Boston University Medical Center, that offers tools to improve the hospital discharge process by preparing patients for discharge from the moment they arrive in the hospital, designating a Discharge Advocate to coordinate discharge with the care team and patient, and improving information with community primary care providers.

Learn more about ProjectRED

Updated version of the ProjectRED Tooklit

Interventions to Reduce Acute Care Transfers (INTERACT2)

INTERACT2 is a quality improvement program designed to improve the early identication, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities.

Learn more about INTERACT2

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions

Institute of Healthcare improvement created a compendium of leading interventions to provide a sampling of the range of effective programs underway to reduce avoidable rehospitalizations across the US.

Download (PDF)

The Commonwealth Fund: Reducing Hospital Readmissions-Lessons from Top-Performing Hospitals

This report offers a synthesis of findings from four case studies of hospitals with exceptionally low readmission rates.

Download (PDF)

Innovations in Reducing Preventable Hospital Admissions, Readmissions, and Emergency Room Use

An Update on Health Plan Initiatives to Address National Health Care Priorities.

Download (PDF)




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