Patient Education and Training

Encore Health Care Transitions Program aims to:

  • Support patients and families;
  • Increase skills among healthcare providers;
  • Enhance the ability of health information technology to promote health information exchange across care settings;
  • Implement system level interventions to improve quality and safety;
  • Develop performance measures and public reporting mechanisms; and
    influence health policy at the national level.

The term “care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness. For example, in the course of an acute exacerbation of an illness, a patient might receive care from a PCP or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she would receive care from a visiting nurse. Each of these shifts from care providers and settings is defined as a care transition.

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