Improving Transitions of Care

This program is no longer active.


When older adults move from one care setting to another, such as from hospitals to nursing homes, or nursing homes to home care, the information that is shared with them and their caregivers is often confusing, contradictory or missing critical parts.

This can cause dangerous errors or delays and lead to serious consequences ‒ many are often readmitted to the hospital due to preventable complications.

To reduce errors and delays, and increase the amount of control patients and caregivers have over health decisions, we supported three collaboratives to improve care transitions. These collaboratives were designed to:

  • Improve health provider understanding of family caregivers’ roles in care transitions and communicate with them more effectively
  • Improve family caregivers’ abilities to manage and coordinate care during and following care transitions
  • Change practice and systems of care to support increased involvement by patients and their caregivers so they can better manage care transitions

In 2005 and 2006, collaborative teams worked on procedures and tools such as uniform transfer forms, medication forms and medication reconciliation processes.

As part of a 2007-2008 Collaborative, 14 teams implemented the Care Transitions Intervention developed by Dr. Eric Coleman of the University of Colorado Health Sciences Center.

In 2009, we expanded our efforts with a Collaborative project, Improving Transitions of Care through Effective Family Caregiver Partnership. The 14 teams in this Collaborative integrated the use of the Care Transitions Intervention with the Next Step in Care: Family Caregivers and Health Care Professional Working Together developed by the United Hospital Fund in New York City.


According to the results of our evaluations, by using the Quality Improvement Collaborative Model developed by the Institute for Healthcare Improvement, teams were able to define, achieve and sustain measurable results.

In addition, a total of more than 100 transitions coaches have been trained in the Care Transitions Intervention.

Program Partners

Collaborative Partners

Funded Partners

Cortland Regional Medical Center
Council for Older Adults
Crouse Hospital
Hospice Buffalo
Hospice Chautauqua
Hospice Palliative Care of Tompkins County
Jones Memorial Hospital
Orleans County Office for the Aging
Salvation Army of Central New York
United Memorial Medical Center