title: Successes and Challenges in Patient Care Transition Programming: One Hospital's Journey.
abstract: The 2013 addition of the Care Transition Measures to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey; enactment of the Patient Protection and Affordable Care Act (2010); and a greater focus on population health have brought a heightened awareness and need for action with patient transitions. Data are emerging from the additional Care Transition Measures and benchmarks have been developed. This article briefly describes the context of care transition. We describe the journey of Indiana University Health North Hospital to overcome patient care transition obstacles, ultimately achieving designation as a top performer. We will discuss our efforts to personalize patient outcomes and transition through activation and improve transitions for vulnerable populations, specifically in the bariatric and orthopedic patient populations. The article concludes with discussion of overcoming obstacles and future directions with continued focus on collaboration and improvement.
authors.forename: Suzanne
authors.initials: S
authors.lastname: DelBoccio
authors.forename: Suzanne
authors.initials: S
authors.lastname: DelBoccio
authors.forename: Debra F
authors.initials: DF
authors.lastname: Smith
authors.forename: Melissa
authors.initials: M
authors.lastname: Hicks
authors.forename: Pamela
authors.initials: P
authors.lastname: Voight Lowe
authors.forename: Joy E
authors.initials: JE
authors.lastname: Graves-Rust
authors.forename: Jennifer
authors.initials: J
authors.lastname: Volland
authors.forename: Sarah
authors.initials: S
authors.lastname: Fryda
mesh_terms: D003142:Communication; D006297:Health Services Accessibility; D006739:Hospital Administration; D007196:Indiana; D007400:Interprofessional Relations; D009937:Organizational Objectives; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge; D017060:Patient Satisfaction; D010360:Patient Transfer / Q000379:methods* / Q000458:organization & administration; D011369:Professional-Patient Relations; D011787:Quality of Health Care