Always Events: Planetree

Same Page Transitional Care: Creating a Template for Optimal Transitions

Organizations: Planetree
Principal Investigator: Michael Lepore, PhD

Always Event(s): Patients will always have the opportunity across healthcare settings to utilize a portable personal health record embedded with actionable patient-driven information, to ensure patients, their healthcare providers and their family members are on the same page with regard to the patient’s healthcare needs, priorities, and lifestyle.

Overview: The overarching goal of this low-cost initiative is to establish a template for the type of transitional care patients should always experience. Specific aims of this initiative include: (1) heightening patients’ and informal caregivers’ confidence in managing healthcare needs, (2) improving the quality of communication, coordination, and collaboration across care settings, and (3) reducing the frequency of unnecessary re-hospitalizations. To accomplish these aims Planetree has launched a multidimensional initiative involving implementation of a validated web-based patient self-assessment tool (How’s Your Health) that offers actionable information about what matters to patients, coordinated with a Care Partner program, wherein the patient and his/her informal (family/friend) caregivers are actively engaged in healthcare planning. Planetree will introduce this Same Page Transitional Care initiative in the context of four hospital and nursing home dyads who have already implemented elements of effective transitional care. All dyads belong to Planetree’s network of patient-centered healthcare organizations, and are therefore skilled and experienced in redesigning care processes with the patient at the center. Same Page Transitional Care is intended to assure that patients, their informal caregivers, and healthcare providers across settings, particularly hospitals and nursing homes, are on the ―same page with regard to patients’ health and healthcare needs, and that this ―page is grounded in patient-reported measures.

Care Partner Agreement

Care Partner Resources

Planetree Same Page Patient Notebook

Same Page Transitional Care- Hospital Pre-Survey

Same Page Transitional Care- Hospital Post Survey

Same Page Transitional Care- Nursing Home Pre-Survey

Same Page Transitional Care- Nursing Home Post Survey

Same Page Transitional Care Website at Planetree



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