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To improve clinical outcomes and quality of life for Californians with chronic disease.

• Expand the number of providers who effectively care for patients with chronic conditions.
• Increase the participation of patients and families in all aspects of care.
• Offer strategies for handling challenges, improving communications, and
maximizing the benefits of family involvement in chronic illness care.

Twenty-five nurses in California will complete the Care Transitions online learning

Rising rates of chronic disease require new modalities of health care delivery in
order to maximize quality of life and the health status of Californian’s. Chronic disease
affects an individual’s level of functioning and their ability to care for him/herself and is
associated with low quality of care. A client with a chronic disease such as hypertension
may need to seek care from several sources, such as a community clinic, private
physician’s office, or cardiologist (Anderson, 2007). One of the most vulnerable
transitions between care settings is after hospital discharge, when a client is discharged
home and they may feel under-prepared to manage on their own and lack an
understanding of their medication (Coleman, 2006). Nurses are in a unique position to
assist clients and their families with chronic disease management by developing clients’
ability for self-care, especially when transitioning between care settings.

Coleman’s Care Transition (CT) model (2002) improves outcomes as clients’

transition between care settings as the model fosters self-reliance in chronic disease
management. CT is a four-week program in which the nurse takes on a coaching role
with the client after their hospital discharge. The nurse-coach builds a working
partnership with the client which is defined by empowering clients and their families to
safely manage their care. A transitions coach provides tools to clients so they can
successfully keep a personal health record with a complete list of current medications,
follow up with medical appointments after discharge and take the correct action if their
condition worsens. The CT model provides nurses a focus in their practice to positively
impact the quality of clients’ care as they move through multiple health care settings.

The challenge of disseminating the CT model to practicing nurses in California

requires innovation. This proposal will facilitate the creation of an online CT learning
module that is user friendly and allows nurses enhance their awareness in preparing
clients to transition between care settings safely. The project’s aim is to get 25 nurses in
California to participate in the CT online learning module and explore results.


8/2009- 6/2010
1. Develop Care Transitions August 2009 Recruit 8 nurses interested in Care Transitions
advisory group
August Clarify roles and responsibilities, set meeting schedule
August Sponsor Webinar on Care Transitions for advisory
August Reserve booth, meeting room & food at November
CINHC conference
September Develop implementation plan with Care Transitions
advisory group
2. Create Care Transitions September
Design online module with IT consultant
online module / tools
Recruit content experts & infuse input on module

October Webinar- launch interactive CT tool

November 2nd Care Transition online module at CINHC conference.

3. Pilot test Care Transition
Have booth set up for nurses* trial online tools with pre-
online module in 25 nurses
post test measures
November 4th- Analyze test results to ascertain if modules are effective
6th in increasing knowledge of Care Transitions.
November Incorporate feedback, seek input from advisory group
7th -20th Create Care Transitions competency certification as
professional development incentive
January 2010 6-8 groups of nurses from various hospitals complete CT
February online module
4. Further testing of Care February Evaluate comments and post test scores of participants
Transitions online Module Final comments from advisory group
March At CINHC conference disseminate Care Transitions
5. Summarize findings
module findings: how-who-outcome
May Write up lessons learned and components for

*Note: Participants will be practicing nurses who spend 25% of the professional role in
direct patient care and no previous experience with formal Care Transitions programs.


California HealthCare Foundation BUDGET 50,000 USD
Two conferences x 2985 each 5970.
California Institute for Nursing & Health Care (CINHC)
Staff & incentive costs 40030.
Indirect costs 4000.
Administration of funds 8% 4000_________
Total 50,000


Intended audiences for this project are practicing nurses in California who will benefit
from the experience gained in the on-line learning activities in caring for clients across
care settings. The stakeholders are clients and their families in various communities in
the state, such as members of the public who pay for health care, and also various
managed care and health maintenance organizations. Of particular interest in improving
the outcomes of people with chronic disease are the government-based insurers such as
MediCal and Medicare, both of which are developing re-imbursement schemes, which
aim to save costs and prevent hospitalizations.
Engage nurses to infuse Care Transitions into their professional nursing roles and
practice. As nurses become competent in transitioning clients with chronic disease safely
between care settings, it may be possible to increase quality of life, and expand the
capacity the clients’ self-care.
The project will be evaluated on the timely implementation of an online Care Transitions
Interactive Module, which will be piloted by no fewer than 25 practicing nurses.
Information on the participants experience with the module and post-test scores will be
summarized and further recommendations made.