Building the Capacity to Disseminate the Care Transitions Intervention on a National Scale

Grant Summary

The John A. Hartford Foundation has made a grant to the University of Colorado to promote at least 45 adoptions of the Care Transitions intervention by health care organizations (hospitals, health plans, or others). The Care Transitions model is a proven, effective method for building self-management skills of older patients and their families to ensure their needs are met during the transition from hospital to home, resulting in lower hospital readmission rates and lower medical costs. Over three years, funding will be used to strategically embed the Care Transitions model in over 45 new sites of care or health plans across the country, and position the Care Transitions team to sustain dissemination of the model through consulting revenue and other funding sources. Specifically, the project will create an infrastructure to promote adoption of the model by conducting an updated environmental scan, developing an enhanced "business case" for adoption of the model, establishing four regional training sessions, and implementing a train-the-trainer program. Additionally, the training program will be enhanced with simulation techniques, "master trainers" will be prepared to lead the regional training sessions, a certification for health professionals trained as "transition coaches" will be developed, and efforts will continue to ensure fidelity of the model as it is adopted in various sites.