Same Page Transitional Care: Creating a Template for Optimal Transitions

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




Planetree has launched a quality improvement and research project as a participant in the Picker Institute’s “Always Event” initiative. In collaboration with Dartmouth College, the Case Management Society of America, Griffin Hospital, Longmont United Hospital, Bethel Health Care, and Bishop Wicke, Planetree is implementing a comprehensive intervention to activate patients in their healthcare, to enhance patient confidence in managing their health, and to improve patients’ experiences when transitioning from one care setting to another. These improvements are being targeted by supporting patients to actively identify and work with Care Partners, who are individuals chosen by patients to collaborate with them in their health care, such as family members, friends, or volunteers. Additionally, participating sites are facilitating patients’ use of the “How’s Your Health” survey tool, which provides patients with a portable medical record to be shared among patients, Care Partners, and healthcare providers, to ensure the full healthcare team is on the ‘same page’ with regard to the patient’s health and heath care needs. Evaluation of these efforts is attending to patients’ levels of confidence.  The project will be complete in Spring, 2012.

For more information please contact:

Michael Lepore, Ph.D.
Director of Quality, Research & Evaluation