Care Transition Models

Core Concepts

The Coleman Care Transitions Program®

Developed by Eric Coleman and colleagues, this program targets older adults leaving the hospital and is built around a transition coach — often a nurse or social worker — who works with the person during admission and for about four weeks after discharge, largely by phone and home visit. The program's four pillars are:

1. Medication self-management — the person builds a current, reconciled medication list and learns to take each drug correctly.
2. A patient-centered record — a personal health record the person owns, containing diagnoses, medications, and the plan, carried to every appointment.
3. Timely follow-up — a visit with primary or specialty care soon after discharge, with the coach helping to prepare for it.
4. A list of red flags — written warning signs of worsening and explicit instructions about what to do.

The coach's goal is activation: building the person's confidence and skill to manage their own care after the program ends.

The Transitional Care Model (Naylor)

Developed by Mary Naylor and colleagues at the University of Pennsylvania, the Transitional Care Model (TCM) is an advanced practice nursing (APRN)-led program for older adults with complex chronic illness. A transitional care nurse (an APRN) follows the person from hospital admission through discharge and into the community, using in-hospital visits, a home visit within 24 hours of discharge, and weekly telephone support for about a month. The APRN coordinates the plan with the primary care provider, addresses medication management and symptom monitoring, and coaches the family. The TCM demonstrates that the skill level of the coordinating clinician matters: complex patients may need an APRN's clinical judgment rather than a lighter-touch coach.

Hospital-based discharge redesign: Project RED and IDEAL

Project RED (Re-Engineered Discharge), developed at Boston University, specifies 12 components of a safe discharge — including medication reconciliation, a written After-Hospital Care Plan in plain language, patient education with teach-back, scheduled follow-up appointments, and a post-discharge phone call. The key idea: discharge is a process to be engineered and tested, not a form to be signed.

IDEAL Discharge Planning, promoted by AHRQ, is a lighter framework any hospital can adopt: Include the patient and family as partners, Discuss the plan in plain language, Educate using teach-back, Assess understanding, and Listen to the person's goals and preferences.

Post-acute and long-term care: INTERACT

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality-improvement program for skilled nursing facilities (SNFs). It provides tools to identify and manage changes in residents' condition on site, improve advance care planning, and communicate better with hospitals — so stable residents are not sent to the emergency department unnecessarily. It shows transitions work both directions: keeping people from leaving a facility for the hospital is also coordination.

Community, technology, and adaptation

Models increasingly lean on community health workers (CHWs), promotoras, and telehealth for culturally grounded follow-up, medication reminders, and linkage to social services. No model is one-size-fits-all: selection depends on the population, the setting, available staffing, and reimbursement. Programs commonly combine components — a hospital may run Project RED-style discharge plus a Coleman-style coach plus CHW follow-up for high-risk patients. Evidence must be evaluated locally: what reduced readmissions at the original site may need adaptation elsewhere, and outcomes must be measured, not assumed.

Scenario: One Patient, Two Model Lenses

Mrs. Okafor, 82, is admitted with pneumonia and new-onset confusion. She has diabetes, takes six medications, and lives alone. Her hospital is deciding between two transition approaches.

Under a Coleman-style program, a transition coach meets her in the hospital, helps her build a personal health record and reconciled medication list, teaches the red flags for pneumonia and diabetes, and schedules a primary care follow-up within a week. After discharge the coach calls at day two and day seven and visits once to review the pillbox. The coach's role is coaching: Mrs. Okafor does the work, with support.

Under the Transitional Care Model, an APRN transitional care nurse follows her from admission, conducts a comprehensive discharge assessment (including cognition, medications, and social supports), visits her at home within 24 hours, and calls weekly for a month — adjusting the plan with her primary care provider when her confusion or glucose control wobbles. The APRN can do more clinical troubleshooting on the spot.

Which is "better"? For an 82-year-old with cognitive change, complex medications, and no local family, the TCM's clinical intensity is the better match; a healthier, well-supported patient might do fine with the coach model. Matching model intensity to patient complexity is exactly the clinical reasoning this topic asks you to practice.

Common Confusions