Massachusetts Senior Care Foundation


Care Transitions

Care Transitions
Care transitions, when patients are transferred from one care provider to another or from one care setting to another, have been associated with high rates of adverse events and a 20% re-hospitalization rate within 30 days of transfer. Improving care transitions is a key strategic priority of the Mass Senior Care Foundation, and the Foundation is leading the way or participating in the following initiatives:

The Care Transitions Education Project
In today’s rapidly shifting health care environment, successful health care organizations must demonstrate that they can contain costs and improve quality care, in alignment with health care payment and delivery system reform. Effective patient-centered care transitions are critical to reducing avoidable re-admissions and related penalties, with nurses playing a key role across sectors.
In 2012, Mass Senior Care Foundation received a Partners Investing in Nursing's Future grant from the Robert Wood Johnson Foundation to support the Care Transitions Education Project. As the lead foundation for this exciting three-year initiative, Mass Senior Care Foundation is working in partnership with the Western Massachusetts Nursing Collaborative to empower more nurses in all settings and roles to lead patient-centered care transitions each and every day.
The Project has developed an integrated curriculum to educate nurses from all settings across the continuum of care – acute care, rehabilitation, long term care, home care, and students – together. CTEP is a unique training program that equips nurses with the foundational knowledge, skills and attitudes required to lead and improve care transitions. Based on the MA Nurse of the Future Competencies©, CTEP provides a customizable curriculum with three major components: 1) Interactive learning modules; 2) Patient tracer experience and; 3) Nurse-led care transitions quality improvement activity. Nurse educators from service and academia developed the curriculum as well as a Train-the-Trainer program.
In 2013, thirty two Western Mass organizations piloted the training curriculum with over 350 nurses and nursing students. Results from the pilot projects demonstrate that individual nurses who completed the CTEP training program increased their skill and knowledge in leading successful care transitions.

CTEP’s innovative approach supports the development of a more engaged nursing workforce better equipped to lead effective care transitions and support organizational initiatives aimed at reducing re-admission rates, and safer handovers. Ultimately, participation in CTEP provides nurses a deeper understating of healthcare systems, how the patient experiences them, and the impact of their contribution within the system.

Now in its final year, the CTEP curriculum has been revised based on an extensive evaluation and will soon be available online. The Foundation is preparing to take the project statewide and will be offering a Train-the-Trainer session in Spring 2014. The Foundation is interested in working with organizations and cross continuum teams in implementing the CTEP program.

To learn more about the Care Transitions Education Project, contact project leaders Carolyn Blanks, Executive Director of the Massachusetts Senior Care Foundation at or 617-558-0202; or Kelly Aiken, Director of Labor & Workforce Development at or 617-558-0202, for more information. 


INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program focused on improving care for residents of skilled nursing facilities and reducing the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures.

INTERACT is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. 


INTERACT was initially developed by Dr. Joseph Ouslander M.D., senior associate dean of geriatric programs at Florida Atlantic University’s Charles E. Schmidt College of Medicine, and colleagues as part of a CMS special study in Georgia from 2006-2008. Preliminary results in reducing avoidable rehospitalizations were encouraging. Ten Massachusetts nursing facilities, along with ten facilities in both New York and Florida, became involved in a 2009 follow up project funded by the Commonwealth Fund to test and evaluate the INTERACT toolkit. These facilities were instrumental in toolkit revisions that resulted in the second generation of the toolkit - INTERACT II.

Early Results:

Results from the 2009 study were compelling, with transfers to the acute care hospital reduced by 17% overall among the participating facilities. Engaged facilities, those with regular attendance on collaborative calls, regular submission of data and highly motivated project leaders, demonstrated a 24% reduction in transfers. Some of the best results were in Massachusetts with one facility reporting a reduction of more than 70% in acute care transfers during the project period.
Additional funding from the Practice Change Fellowship allowed more than 100 additional sites to receive training on the INTERACT toolkit in 2010-2011. Most Massachusetts skilled nursing facilities have received training and have either implemented or are in the process of implementing the INTERACT Quality Improvement Program. 


For more information about INTERACT click here.

Check out other information on improving care transitions. 

 Resources for preventing re-hospitalization

Massachusetts Care Transitions Forum LINK