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Coordinated Transitional Care
Share PrintThe Coordinated Transitional Care program (CTraC) is an evidence-based, nurse-led program specifically designed to meet VA’s need for an inexpensive approach to transitional care that can serve a geographically dispersed population. The goal of CTraC is to reduce hospital readmission, improve post-hospital outcomes, and empower Veterans/families during the early post-hospital period.
Origin:
January 2012, William S. Middleton Memorial Veterans' Hospital (Madison)
Adoptions:
13 successful, 2 in-progress
Awards and Recognition:
GRECC Promising Practice, Rural Promising Practice
Partners:
Geriatric Research Education and Clinical Center
Recent Updates
Overview
Problem
Journeying through the healthcare system can present significant hurdles for Veterans, particularly when transitioning from hospital to home. This period often involves navigating complex medication regimens, understanding new or adjusted treatment plans, and ensuring timely follow-up appointments are scheduled and kept. Without robust support and clear comm
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Journeying through the healthcare system can present significant hurdles for Veterans, particularly when transitioning from hospital to home. This period often involves navigating complex medication regimens, understanding new or adjusted treatment plans, and ensuring timely follow-up appointments are scheduled and kept. Without robust support and clear communication during these critical junctures, Veterans may experience confusion, feel overwhelmed, and face challenges in effectively managing their health in their new care environment. These difficulties can lead to negative consequences, including preventable hospital readmissions, delays in accessing necessary outpatient services, and an increased risk of complications.
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CTraC is designed to bridge the gap between hospital and home
Solution
Addressing the complexities Veterans face when transitioning from hospital to home requires a dedicated and supportive approach. The protocol is designed to be administered over the course of 30 days which includes an initial hospital visit where the registered nurse introduces themselves, reviews the CTraC program, sets-up a follow-up call, and reviews esse
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Addressing the complexities Veterans face when transitioning from hospital to home requires a dedicated and supportive approach. The protocol is designed to be administered over the course of 30 days which includes an initial hospital visit where the registered nurse introduces themselves, reviews the CTraC program, sets-up a follow-up call, and reviews essential information (e.g., symptom management, contact information, medical follow-up). Within 48 hours of the Veteran’s discharge, the CTraC NCM completes an initial phone call that lasts approximately 45 minutes; it includes a tailored nursing assessment, reasons to call (“red flags”), medication reconciliation, medical follow-up/appointment set-up, and review of important contact information. The remaining phone calls occur weekly and last anywhere from 15-30 minutes depending on the Veterans needs and entails an abbreviated version of the initial phone call. Veterans and nurses make additional calls unique to each Veteran’s case. Veterans are discharged from the program when; a) the patient and the CTraC nurse both agree that no further follow-up calls are necessary; or b) four weeks have passed. The CTraC nurse is often the only individual in the healthcare system who accompanies the patient across their care transition. CTraC does not duplicate or replace existing care; it fills the gap between inpatient and outpatient services and provides more intensive symptom assessment, medication reconciliation, and case management than is possible by primary care. By targeting patients at increased risk of readmission, CTraC focuses resources on those who need it most.
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CTraC Workflow
Results
The development of CTraC was informed by a review of existing evidence-based transitional care programs and incorporates key elements of effective care transitions tailored to the VA setting and Veterans' unique needs. Its success has led to dissemination within the VA system, highlighting its strong evidence base and widespread acceptability. Ongoing resear
...
The development of CTraC was informed by a review of existing evidence-based transitional care programs and incorporates key elements of effective care transitions tailored to the VA setting and Veterans' unique needs. Its success has led to dissemination within the VA system, highlighting its strong evidence base and widespread acceptability. Ongoing research continues to evaluate and adapt the CTraC model for various Veteran populations and healthcare settings.
- Reduced Hospital Readmissions: Multiple studies conducted within the VA have shown that the CTraC model is associated with a significant decrease in 30-day hospital readmission rates for participating Veterans. Some studies have reported reductions of up to one-third or even 54% in specific populations (i.e., CHF, COPD).
- Cost Savings: By preventing costly hospital readmissions, CTraC has demonstrated significant cost savings per Veteran enrolled in the program. Estimates suggest savings of up to ~$1,800 per patient.
- Improved Patient Safety: Identifying and correcting medication discrepancies is a hallmark of the program translating to safer medication management. Veterans are also connected to needed referrals and interventions, facilitating connection to needed services and supports.
- Adaptability to Different Settings: While initially developed for hospital-to-home transitions, the CTraC model has been successfully adapted for other high-risk transitions, such as from the hospital to skilled nursing facilities (COMPASS), from skilled nursing facilities to home (CLC CTraC), and to support Veterans living with serious illness (Supportive CTraC). See more
- Reduced Hospital Readmissions: Multiple studies conducted within the VA have shown that the CTraC model is associated with a significant decrease in 30-day hospital readmission rates for participating Veterans. Some studies have reported reductions of up to one-third or even 54% in specific populations (i.e., CHF, COPD).
- Cost Savings: By preventing costly hospital readmissions, CTraC has demonstrated significant cost savings per Veteran enrolled in the program. Estimates suggest savings of up to ~$1,800 per patient.
- Improved Patient Safety: Identifying and correcting medication discrepancies is a hallmark of the program translating to safer medication management. Veterans are also connected to needed referrals and interventions, facilitating connection to needed services and supports.
- Adaptability to Different Settings: While initially developed for hospital-to-home transitions, the CTraC model has been successfully adapted for other high-risk transitions, such as from the hospital to skilled nursing facilities (COMPASS), from skilled nursing facilities to home (CLC CTraC), and to support Veterans living with serious illness (Supportive CTraC). See more
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CTraC Outcomes
Supportive CTraC Outcomes
Metrics
- Number of Veterans served
- 30-day hospital readmissions
- 30-day emergency department visits
- Medication discrepancies identified/resolved
- Primary care follow-up appointment attendance
- Referrals/interventions provided
- Cost/Return on investment
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Multimedia
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CTraC in action
Implementation
Departments
- Primary care
- Hospital medicine
- Geriatrics
- Discharge planning
Core Resources
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About
Original team
Caroline Madrigal
National Program Coordinator
Jane Driver
CTraC Program Developer
Amy Kind
CTraC Program Developer
Laury Jensen
CTraC Program Developer
Comment
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