A critical element of the Care Transitions model is empowering the patient to play a stronger and more effective role in her or his transition from the hospital to the home or across health care settings. The patient is the common element across these settings; therefore, s/he is often in the best position to ensure a smooth care transition.
At the beginning of the intervention, each patient establishes a goal s/he wants to achieve with the program, and the Transition Coach helps the patient work towards achieving that goal. The establishment of a personal goal helps the patient remain committed to managing her/his care, as well as ensures the patient-centered focus of the program. Patients are more motivated to pursue their own identified goal rather than one identified by a health care professional. This helps creates a “pull” rather than a “push” dynamic.
The model has been implemented in a variety of communities, including predominantly Spanish-speaking communities, rural communities and inner-city urban communities. In some cases, the model has been modified to meet the needs of individuals with limited health literacy.
Health care professionals are largely trained to become “doers”. Stepping out of this role can be challenging for some and not everyone can make the shift from being a doer to being a coach. Coaches do not provide skilled care per se but rather coach patients to do as much as they can for themselves. The best coaches “keep their hands in their pockets” and generally do less talking and more listening. Coaches understand that making this investment in their patients will pay dividends in the present as well as in the future.
The Care Transitions Program has become increasingly convinced about the importance of maintaining model fidelity to the Care Transitions Intervention. Should health care organizations modify the model or not take proper steps to adopt the model as developed, it is not assured they will achieve the same outcomes with respect to reducing cost and utilization.