This document outlines a project aimed at establishing a sustainable process for patient-centered care transitions. The goals were to (1) address what matters to patients, (2) provide actionable health information, and (3) share information across care settings. Partners implemented a process using an electronic personal health record called "How's Your Health" to survey patients in the hospital and after discharge. Results showed patients were more confident after hospital discharge but less so after skilled nursing discharge. Sustainability varied by site but engaged volunteers were key. Additional funding was received to focus on diabetes patients. Lessons included tailoring health IT to settings and supporting older adults, garnering volunteer interest, and engaging designated caregivers or volunteers.

1. Same Page Transitional Care
Creating a Template for Optimal Transitions
SPECIFIC AIMS
The Same Page Transitional Care Always Event aimed to establish a sustainable patient-centered pro-
cess whereby patients would have the opportunity to utilize an electronic personal health record that: (1) ad-
dresses what matters to the patient, (2) provides actionable information to support health and well-being,
and (3) can be shared across care settings to ensure patients, their family caregivers, and healthcare pro-
viders all are on the same page with regard to the patients’ health and healthcare needs.
Planetree partnered with colleagues from Dartmouth College, the Case Management Society of America, Longmont United Hospital and
Transitional Care Unit, Wesley Village, Bethel Health Care, and Griffin Hospital on the Same Page initiative
Key Components of Patient-Centered Care
Text and Video Resources to Support Care Partner Programs and use of How’s Your Health
Process
Resources
Individuals
EXTENT OF IMPLEMENTATION # Patients with Care
 219 patients utilized How’s Your Health
Age Group Partners Utilizing HYH
 142 patients surveyed while in the care settings and ~3 days after discharge
65-74 72
Key Findings 75-84 76
 Hospital results are favorable: Patients are more confident (13/13 PAM items)
 SNF results are mixed: Patients are less confident (5/13 PAM items)
85+ 45
 Patients who are more confident in being able to manage their health have bet- <65 8
ter quality of life Age unknown 18
Total 219
87 Hospital
142 Participants
55 SNF
Average Age 76.9
Patient Activation Measure results
Intervention Difference (ID) - Hospital SNF
Control Difference (CD)
Positive ID-CD 13 5
Neutral ID-CD 0 3
Negative ID-CD 0 5
SUSTAINABILITY
Implementation of the Same Page Transitional Care process varied across the five sites of care according to local re-
sources and needs. Variations showed that a key attribute for sustainable implementation is the engagement of volun-
teers. Additional funding has been garnered to support Phase 2 of work.
PROCESSES FOR VOLUNTEER ENGAGEMENT IN SAME PAGE TRANSITIONAL CARE
 Volunteers recruited from community health education groups, targeting retired healthcare professionals
 Volunteers attend hospital volunteer orientation and Same Page training with master coach RN
 Volunteers bring iPad to patient room, meet patient, and facilitate completion of on-line HYH survey
 Post-discharge volunteers do one or more home visits, three or more follow-up phone calls, plus other transitional care strategies
 Volunteers meet every Tuesday at hospital to share experiences and address questions or concerns
PHASE 2 FUNDING
 Improved Medication Reconciliation and Self Management Support for Diabetic Patients throughout the Discharge Transition (Sanofi)
 Utilizing HYH [including new SNF/Outpatient version] with focus on improving health confidence and reducing readmissions among patients with diabetes
KEY LESSONS LEARNED
 Health Information Technologies (HIT) may require setting-specific design
 Introducing new HIT (e.g., HYH, iPads) to older adults is feasible with personnel support
 HIT can garner volunteer interest among college-aged/-educated adults, retired health pros
 Care Partner programs may be implemented with a focus on caregivers identified by patients
Tools and Resources available at :
(e.g., family, friends) or with a focus on volunteers www.planetree.org > Resources & Tools