Easing the
transition from
hospital to home

CareTransition

CareTransition is a complementary program that enhances the hospital discharge process and improves a patient’s ability to manage their own recovery.

Reducing unplanned admissions

CareTransition is for patients who are most at risk of an avoidable readmission after discharge from hospital.

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Who is CareTransition for?

CareTransition is for patients with medium-to-high risk of an avoidable readmission after discharge from hospital. Eligible patients are identified by a predictive analysis based on their medical history.

Support services

CareTransition offers comprehensive hospital discharge and follow up support to decrease readmissions, including:

  • a home visit by a CareTransition Coach to set health goals
  • phones calls from a dedicated CareTransition Coach for ongoing support through the transition period
  • an information pack to help track health conditions, medications and appointments.

Program duration

The CareTransition program runs for 30 days, focusing on the critical post-discharge period.

GP Practice registration

CareComplete helps build practice capacity to offer evidence-based chronic condition management services. The programs are designed to enhance existing chronic disease management practices without requiring significant time or investment from clinic staff.


For further information please call the CareComplete team on 1300 650 742









Case study: Geoff

Age: 89   Health details: Geoff is recovering after having a carcinoma removed 
from his left eye. He lives alone in a two storey house.

“I feel like I have my life back again. Since leaving hospital I no longer feel drowsy all the time.”

Geoff has been feeling “like a ‘zombie’, going blank and pale as though he was disappearing from his body.” These ‘zombie’ episodes occurred every day, stopping him from daily activities, and had been so severe that passers-by had called an ambulance on more than one occasion.

Although Geoff was referred to CareTransition after his eye surgery, he told his CareTransition coach that he was particularly concerned that his overall medication regime could be contributing to his poor quality of life.

Geoff had been taking more than 20 medications, including five different blood pressure medications, which he took together at breakfast at around 7am.

Action

Hospital Care Transition Icon Medical Helper Care Transition Icon
  • A home medication review
  • An appointment with his GP, who helped him schedule an earlier appointment with his cardiologist due to concerns he was over-medicated

Results

  • Geoff’s cardiologist adjusted his medications
  • Geoff now understands the risks and benefits of each medicine, and is monitoring his blood pressure at home every day
  • The changes in Geoff’s medication regime have had an immediate effect on his wellbeing
  • He no longer feels like a ‘zombie’ and has added back in daily usual activities

Patient’s name and photo have been changed for privacy purposes.

Evidence

CareTransition is based on a rigorously evaluated program developed by the University of Colorado which complements the existing discharge process and supports patients to take an active role in their care.

The program (Care Transitions Intervention) has been evaluated in two randomised controlled trials with about 850 people. Participants in the intervention were significantly less likely to be readmitted to hospital, and the benefits were sustained for five months after the end of the one-month intervention period.1,2

The program has since been was implemented by over 900 organisations in 44 states in the United States. Other studies have shown significant drops in 30 day readmissions rates as well as 60-day and one year readmissions.3,4

An analysis of programs to reduce readmission in high risk patients found that support during the transition period after hospitalisation was a key component of successful interventions.5

Other reviews support the effectiveness of interventions aimed at improving medication management to reduce hospitalisation rates.6,7

References: 1. Coleman EA, et al. The Care Transitions Intervention: Results of a Randomised Controlled Trial. Archives of Internal Medicine, 2006, vol. 166, pp. 1822–1828. 2. Parry C, et al. Further Application of the Care Transitions Intervention: Results of a Randomised Controlled Trial Conducted in a Fee-For-Service Setting. Home Health Care Services Quarterly, 2009, vol. 28, pp. 84–99. 3. Care Transition. Evidence and Adoption. Available online: www.caretransitions.org/documents/Evidence_and_Adoptions_2.pdf last accessed: 4 Nov 2015. 4. Fenfang Li, et al. The Kauai Care Transition Program at Kauai Veterans Memorial Hospital. Hospital Discharge Planning Grant Final Evaluation Report, Report to the twenty-eighth legislature state of Hawaii, 2013. 5. Scott IA. Public hospital bed crisis: too few or too misused?, 2010, Aust. Health Review 34, 317–324. 6. Simoens, S., et al., Review of the cost-effectiveness of interventions to improve seamless care focusing on medication. International journal of clinical pharmacy, 2011. 336: 909–917. 7. Brown, R.S., et al. Six Features Of Medicare Coordinated Care Demonstration Programs That Cut Hospital Admissions Of High-Risk Patients. Health Affairs, 2012. 31(6): p. 1156–66.