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 readmissions 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 maintain 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 readmissions; and provide better access to more appropriate and cost-effective health care.


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.


For more information, please contact Honora Englander, MD, OHSU, at

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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.