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Hospital-to-home transition program creates bridge for better health

Key members of the Care Transitions Innovations (C-TraIn) team
Key members of the Care Transitions Innovations (C-TraIn) team have included, from left, Devan Kansagara, M.D., M.C.R; Stephanie Peña, R.N.; Jackie Sharpe, PharmD; Char Riley; Nic Granum; Honora Englander, M.D.; and LeAnn Michaels.

Luis Ubiles, 61, of Portland, landed in the emergency department after about a year of headaches, coughing and not feeling well. His blood pressure was life-threateningly high when he was rushed to Oregon Health & Science University.

"We create a bridge from hospital to home," said Honora Englander, M.D.

He had lost his job as a system analyst when the economy crashed; he didn’t have health insurance and could not afford his blood pressure medications.

During his 10-day hospital stay at OHSU he was enrolled in an innovative program to help patients transition from hospital to home so that their conditions stay stable, they connect effectively with primary care, and their health improves.

"We create a bridge from hospital to home," said Honora Englander, M.D.

Englander, with Devan Kansagara, M.D., M.C.R., assistant professors of medicine at OHSU, helped create the Care Transitions Innovation, or C-TraIn program. OHSU is part of Health Share of Oregon, a coordinated care organization (CCO). This program is an example of how coordinated care helps patients get better care and improved health.

"Patients said they had difficulty managing their illnesses. They were confused about their medicines or couldn't afford them and they needed follow-up care," Englander said.

The C-TraIn team – nurses, pharmacists and physicians across the hospital and clinic settings – starts providing enhanced care coordination when the patient enters the hospital. For example, a pharmacist taught Ubiles about how to take his pills and provided him the first 30 days of his medications. After that, his prescriptions are available free or at low cost from partnering clinics. They connected Ubiles to the Old Town Clinic in Portland, one of three partner clinics, for free follow-up care. A team nurse visited him in the hospital and at home. She taught him how to check his blood pressure and how to spot signs his blood pressure is rising.

Now, a year later, Ubiles has stayed out of the hospital. He sees his Old Town Clinic doctor monthly. And he takes his medicines regularly.

"The care I’ve had has been fantastic. I feel so much better. I don’t ever want to have any more close calls," he said.

The C-TraIn team has "continuous improvement" meetings monthly. The team has helped more than 250 patients since it began in November 2010 and soon it will be rolled out to three Legacy Health System hospitals, which are part of Health Share of Oregon.