Same Page Transitional Care

In Collaboration with




What is Same Page Transitional Care?

Same Page Care is experienced by patients when all members of their healthcare team—including the patient him/herself, any informal caregivers and their healthcare providers—all share a common understanding of the patient’s healthcare history, needs, priorities and wellness goals.

The patient and his/her loved ones who take on the role of caregiver are integral members of the healthcare team.  As patients transition from one setting of care to another and interact with a revolving cast of doctors, nurses and other providers, many struggle to coordinate their care.  Given the complexity the healthcare system and the often emotionally charged nature of dealing with health issues, this coordination of care is a challenging proposition.

The Same Page Transitional Care Initiative equips patients, their loved ones and healthcare providers with practical tools to facilitate everyone being on the same page, including:

  • Resources to support family members’ involvement as Care Partners who are integrated as important members of the care team
  • The How’s Your Health (HYH)survey, developed by Dartmouth College that queries patients about their priorities for their health and wellness and generates actionable information to be used by providers to ensure what matters most to the patient is a shared goal for the whole healthcare team
  • Tools to enhance patients’ ability to understand their plan of care and manage their health
  • Resources for training healthcare professionals to support Same Page Transitions.

We invite you to download these resources at no charge as your organization embarks on a journey to implement your own Same Page Transitional Care Initiative.

*COMING SOON: To hear about the steps to implementation please download the “Same Page Transitional Care” webinar.  

 Background on the Same Page Transitional Care Initiative

Planetree launched the Same Page Transitional Care quality improvement and research project in 2011 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 Health Center, Planetree implemented 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. The Same Page Toolkit available here has been developed to share the lessons learned, resources developed and effective practices established during phase one of the study.

In Phase 2 of this work, supported by Sanofi Aventis, we will continue to explore facilitators and barriers to Same Page Care, with a specific emphasis on the experience of patients with diabetes.


For more information please contact:

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