A Massachusetts program has developed a number of resources for improving transition of care that are now available for healthcare facilities to use at no cost.

The Care Transitions Education Project (CTEP) is a strategy that focuses on effective patient care transitions, explains Cherelyn Roberts, RN, manager of community navigation/transitional care at Holyoke (MA) Medical Center, one of the participating hospitals.

Holyoke focused on readmissions and improving transitions, encouraging warm handovers and the extra steps to make sure the patient gets connected with services and professionals after discharge.

“When people leave our hospital and go into any environment now, we want to see a warm handover. With our complex heart patients, we have a warm handover in 90% of those cases,” Roberts says. “To me, that’s the biggest benefit from CTEP. Our hospital, and other hospitals in our area are still implementing it and still teaching it. It’s a way to bring us all together and understand each other’s setting, how things are different and what we need to do to have a safe, effective, low-cost transition.”

Nursing schools and other organizations in the community also focus on warm transitions, which helps when a professional moves from one school or facility to another, Roberts says.

“This is a must, that we’re all speaking the same language,” she says.

The program was piloted with 350 nurses and nursing students, says Jena Bauman Adams, MPH, director of special projects at the Center for Health IMPACT in Worcester, MA.

“Our evaluations showed that the most powerful parts of the program were bringing together nurses from different settings for some face-time training,” Adams says. “If we had developed it to be all online, they would have missed out on a lot of the learning opportunity, and especially the attitude change.”

Roberts agrees, saying the interaction between nurses of different settings helped eliminate a lot of turf issues.

“It was helpful for them to speak to each other as actual people and to realize that a hospital nurse, for instance, wasn’t only concerned about patients while they were in the hospital, but actually did have interest and concern about the next facility or caregiver,” Roberts says. “Having people speak to each other face-to-face breaks down some barriers and significantly improves communication.”

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