Massachusetts care transitions education project: Improving effective person-centered care transitions across the healthcare continuum

Healthcare providers are increasingly pressed to deliver person-centered, seamless care for patients coming and going from multiple settings, including hospitals, skilled nursing facilities, primary care, community clinics, rehab, home health, hospice, and long-term care – each with its own array of caregivers, care teams and processes.  Improving the quality of care transitions from one setting or one set of providers to another during an episode of care can save lives, reduce adverse events and disabilities due to gaps or omissions in care, prevent avoidable hospital readmissions, and is essential to achieving the "Triple Aim” (Institute for Healthcare Improvement) of improving the patient experience of care; improving the health of populations; and reducing the per capita cost of health care.  

As the largest segment of the nation’s healthcare workforce and close to patients in all care settings, nurses are "uniquely positioned" to improve care transition processes and outcomes (IOM 2010 Future of Nursing report).  The Care Transitions Education Project (CTEP) focuses on improving the knowledge, attitudes and skills nurses need to execute effective, patient-centered care transitions - competencies that are applicable in nurses' individual practice as well as to nurses' roles in any care transition improvement model or approach.  The 30-hour CTEP curriculum is comprised of three main components: four interactive learning modules, a “patient tracer” experiential learning activity, and a care transitions quality improvement project.

CTEP was implemented successfully in 2013 in eight pilots involving 28 healthcare facilities (acute care, home health, nursing homes, rehab, assisted living, adult daycare, primary care, long-term care) and five nursing schools.  167 staff nurses, 186 nursing students and 30 nurse educators participated.  A rigorous external evaluation showed that the CTEP experience:

• Improved nurses' knowledge, skills and attitudes for executing effective care transitions;
• Increased nurses' awareness of patient care, staffing, strengths and challenges of care settings beyond their own; 
• Increased collaboration among participants; and
• Produced ongoing nurse-led care transition quality improvement initiatives.

CTEP can be implemented as professional development or continuing education for staff nurses; added to new employee orientation; integrated into nursing school curriculum; or implemented as a cross-continuum quality improvement initiative to improve the quality of care transitions, reduce re-admission rates, and improve patient satisfaction.  For individual learners, CTEP offers a broader understanding of healthcare systems, patients’ experiences within them, and their own actual and potential impact on quality of care outcomes.