A care transition is defined as the movement of a patient  from one health care practitioner or setting to another as their condition and care needs change  A set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations and/or levels of care in the same location is defined as transitional care. When the transitional care process is not coordinated properly, the patient is left in a vulnerable state and at an increased risk of rehospitalization. 

In 2008, the concept of improving care transitions was very new.  Few recognized the need for improvement in the care transitions process or that it could be re-engineered in a positive way. Things have changed.

During the 9th Scope of Work, CIMRO of Nebraska was awarded one of 14 contracts across the country by CMS to conduct a cutting-edge initiative to improve care transitions between healthcare settings. CIMRO of Nebraska’s local project, CareTrek™, was implemented in the Omaha metropolitan community. Visit the CareTrek page to learn more.

Effective evidence-based interventions to reduce hospital readmissions and improve care transitions are available. Visit this section of our website for resources and information on national and local initiatives to support this effort.