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 patient-centered care transitions is a key strategic priority of the Mass Senior Care Foundation. 


The Massachusetts Senior Care Foundation hosts the Care Transitions Education Project (CTEP), an innovative workforce training strategy to equip frontline nurses to lead and improve patient-centered care transitions.  Visit the CTEP website for access to a free downloadable curriculum that can be used to educate nurses from across care settings, increasing their ability to communicate and collaborate to achieve common patient-centered goals, including reducing avoidable hospital re-admissions.  

CTEP was initially developed and piloted by the Massachusetts Senior Care Foundation and Western Massachusetts Nursing Collaborative through a Robert Wood Johnson and Northwest Health Foundation’s Partners Investing in Nursing’s Future Initiative. For more information about CTEP visit or contact Carolyn Blanks, Executive Director, Mass Senior Care Foundation at or 617-558-0202.  

See press release (get hyperlink) for more information about the Foundation’s current CTEP activities.  


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