Contact Us

we help reduce readmissions and costly penalties and improve the readiness of your transitional care team

CareCases for CareTransitions

Download PDF Download the CareCases Brochure

CareCases for CareTransitions Brochure Cover

One in five Medicare patients are readmitted to the hospital within 30 days of discharge, resulting in a tremendous cost to the healthcare system and less than optimal patient outcomes. The causes of these unnecessary readmissions can result from breakdowns in communication, patient education, and care team accountability, or may be due to patient psychosocial factors.

CareCases for CareTransitions Transition Planning

CareCases for CareTransitions provides an online case-based curriculum to teach communication and coordination among inter-disciplinary care teams. This team-based training curriculum consists of 10 cases, each addressing a distinctive challenge faced by care providers. The curriculum teaches care teams to improve transitions of care and reduce readmissions. It is based on the 7 Essential Elements in Care Transitions developed by the National Transitions of Care Coalition including:

  1. Medications Management
  2. Transition Planning
  3. Patient and Family Engagement / Education
  4. Healthcare Providers Engagement
  5. Follow-Up Care
  6. Information Transfer
  7. Shared Accountability across Providers and Organizations


CareCases for CareTransitions Case Introduction

CareCases for CareTransitions identifies roles, responsibilities, and unique contributions of each team member in providing the best care and avoiding unnecessary readmissions.

CareCases for CareTransitions Patient Meeting

Watch this brief video about CareCases for CareTransitions:

Key Components

  • Teaches interdisciplinary care teams communication, coordination and collaboration across multiple healthcare settings
  • Improves individual and team aptitude, proficiency and critical thinking
  • Provides private collaborative tools for team interactions and peer-to-peer problem solving
  • Built on industry best practices, complementing any Transitional Care model
  • Helps avoid readmission penalties while improving patient care