The Care Transitions Innovation (C-TraIn) aims to improve healthcare quality for hospitalized patients as they transition from inpatient to outpatient care. Through improved care coordination, patient education, and enhanced access to outpatient care, C-TraIn’s goal is to improve quality and the patient experience and to reduce high-cost inpatient utilization by reducing readmissions and post-hospital emergency department visits.
The hospital-to-home transition marks an abrupt paradigm shift from intensive, provider-initiated care to self-managed care in which patients are primarily responsible for maintaining day-to-day health and negotiating follow-up, medications, transport, and equipment needs. Patients are at risk for adverse drug events and increased morbidity and mortality if transitions are executed poorly, and poor transitions have been associated with increased risk of re-hospitalizations and emergency department use. Socioeconomically disadvantaged patients with chronic illness face unique challenges at transitions. External barriers such as lack of transportation, confusion about follow-up, uncertainty about medication changes, and financial constraints represent important targets for improving the inpatient to outpatient care transition.
C-TraIn has four major components that target the specific needs of uninsured and low-income publicly insured patients, including:
A Transitional Care Nurse who bridges care and provides self-management patient education
Pharmacy consultation to tailor medication regimens, assess barriers, and provide support for discharge medications for the uninsured and those without prescription drug coverage
Clinic and hospital linkages that promote improved access and care coordination
Monthly team meetings that convene diverse, multidisciplinary providers from across the care continuum to engage in quality improvement and systems integration
The intervention supports improved clinical outcomes, reduced use of emergency rooms, fewer avoidable hospital readmissions, and better access to a more appropriate and cost-effective level of health care services.
C-TraIn was developed and studied in a randomized controlled trial at OHSU. The grant supports scaling C-TraIn and provides a forum to share best practices and lessons learned across Health Share of Oregon partner organizations. Particular focus will be given to change management within partner organizations to ensure successful community-wide implementation. The Health Commons Grant funds hiring Transitional Care Nurses, pharmacists, physician champions, and a project manager.
|Year 1 (July 1, 2012-June 30, 2013)|
|Staffing plan: 8.6 FTE including Transitional Care Nurses, specialists within partner organizations, project manager|
|Grant funds: $839,461|
|Potential impact: 520 patients|
For more information, please contact Honora Englander, MD, OHSU, at firstname.lastname@example.org
C-TraIn Operational Team: Honora Englander, MD (OHSU), Devan Kansagara, MD (OHSU/VA), Jackie Sharpe, PharmD (OHSU), Maggie Weller (HSO); OHSU C-TraIn Team: Lea Croft, RN, Annie Robb, RN, Lori-Ann Lima, RN, Brandon Tieu, MD, Chris March, MD, Sarah Power, Social Work, Nancy Trumbo, Care Mgr, Anita Murrin, Informatics; Legacy C-TraIn Team: Carol Larson, RN, Kathy Loos, RN, Paula Bote, RN, Mikeanne Minter, MD, Kevin Breger, MD, Charlie Hu, MD, Claudia Wilson, RN, Carol Shook, Care Mgr, Kathy Stoner, Pharmacy Lead, Mark Stone, Informatics
Luis Ubiles, 61, of Portland, landed in the emergency department after about a year of headaches, coughing and not feeling well. His blood pressure was life-threateningly high when he was rushed to Oregon Health & Science University. He had lost his job as a system analyst when the economy crashed; he didn’t have health insurance and could not afford his blood pressure medications. During his 10-day hospital stay at OHSU, he was enrolled in the C-Train program. Now, a year later, Ubiles has stayed out of the hospital. He sees his Old Town Clinic doctor monthly. And he takes his medicines regularly.
“The care I’ve had has been fantastic. I feel so much better. I don’t ever want to have any more close calls,” Ubiles said.