Tools for Promoting Patient Activation and Self-Management for Care Transitions Intervention® Participants

California Care Transitions Program


The California Care Transitions Program was developed by Aging & Independence Services (AIS), the Area Agency on Aging for San Diego County and lead agency for San Diego’s Aging and Disability Resource Center (ADRC). AIS implemented the Care Transitions Intervention® (CTI) Program in August 2010 in collaboration with Sharp Memorial Hospital. In November 2011, the CTI Program was expanded to two additional hospitals, Scripps Mercy, San Diego and the University of California San Diego (UCSD) Medical Center.

The overarching goal of the California program was to reinforce patients’ adherence to the four pillars of the CTI evidence-based practice. Specifically the program focused on extending the effect of the four-week CTI program through adoption of an electronic personal health record (PHR). This goal was achieved by activating chronically ill patients to use a web-based tool, the Network of Care (NoC), to 1. manage their chronic conditions, 2. engage their “team” of formal and informal caregivers to support them through an electronic PHR, 3. to locate needed services and resources for their long term care needs, and 4. to use an online health library as a resource to improve their health outcomes. Transition Coaches offered all CTI participants the opportunity to use the web-based tool instead of a paper medication list and PHR. Patients who elected this option received one-on-one support from the Program Technical Coordinator. In addition, training on the NoC was provided to 127 healthcare providers throughout the community to encourage use of this web resource by chronically ill patients and their health care providers.

The program produced a number of positive results. Patients with chronic conditions who used the web-based program to self-manage their health have maintained continuous use of the NoC web resource. Patients continue to use the health library and other online resources to search for information related to their health conditions or medications as well as continue to maintain their electronic PHR. The most significant finding was that activating patients to better manage their chronic conditions through CTI and the use of the electronic PHR contributed to reducing the rate of hospital readmissions.

Success in reducing hospital readmissions resulted in the program being incorporated into the San Diego Care Transitions Partnership’s (SDCTP) application to the Centers for Medicare & Medicaid Services (CMS) Community Based Care Transitions Program (CCTP). The SDCTP program would expand the program for use with more than 10,000 chronically ill patients transitioning from 13 hospitals in San Diego to other care settings annually.


The organizations involved in implementing the program were: The County of San Diego, Health and Human Services Agency, Aging & Independence Services (AIS); Sharp Memorial Hospital; Scripps Mercy Hospital, San Diego; UCSD Medical Center; The San Diego Futures Foundation; and Trilogy Integrated Resources, Inc.


Problem Addressed: Communication problems and other errors occur as patients move across the continuum of care and are discharged back to the community. Failure to communicate critical information related to a patient’s medical care, chronic conditions, medications, and the importance of follow-up care often result in avoidable readmissions. Patients can help reduce their own chances of readmission if they are activated to self-manage their chronic conditions, maintain an accurate medication list, and engage their “team” of caregivers through an electronic PHR.

Patient Population: Thirty-one patients participated in the Program. The group was distributed as follows: 53% were female and 47% were male; 35% were Caucasian, 16% African-American, 12.5% Asian, 6% Latino, and 30.5% listed themselves as “other.” The average age of Program enrollees was 59 years old. The primary diagnoses of this cohort included Cellulitis (16%), Pneumonia (16%), Diabetes (12.5%), CHF (12.5%), COPD (10%), and other conditions (33%) including hypertension, gout and urinary tract infection.

Description of Program: The AIS NoC web site,, is a comprehensive, Internet based, free resource for older adults and people with disabilities and their formal and informal caregivers. The site contains an electronic PHR, which is stored on a HIPPA compliant VeriSign-encrypted server; an extensive library with more than 30,000 articles, fact sheets, and reports and a local service directory. By using the PHR on the NoC, health conditions and medications, provider, legal and insurance information can be readily updated by the CTI patient. The PHR can be printed or shared with the support “team.” The owner of the PHR can also engage their “team” to use the PHR to communicate with one another as well as import patient/client assessments, treatment plans, and test results. Additionally, CTI patients can use the NoC website to locate needed services and resources, learn about their medications and chronic conditions, create a wellness plan, and plan for their long-term care service and support needs.


The results from 23 patient surveys indicate that after participating in the Program, patients were activated for health self-management. All patients utilizing the NoC web site and the electronic PHR to self-manage their chronic conditions avoided a 30 day hospital readmission.

Survey Results:

  • 70% of the Program participants continue to update the personal health record and medication list.
  • 96% of the Program participants followed up with their health care providers.
  • 78% of the Program participants stated that the quality of care that they received improved since participating in the Care Transitions Intervention Program.
  • 100% of the Program participants have a better understanding of the warning signs associated with their chronic health condition(s).
  • 96% of the Program participants feel more confident in their ability to manage their chronic health condition(s).
  • 79% of the Program participants use the Internet to help them manage their health.
  • 72% of the Program participants who use a computer to help manage their health utilize the Network of Care website.
  • 86% of the Program participants who use a computer to help manage their health utilize the Personal Health Record and Medication List.
  • 36% of the Program participants who use a computer to help manage their health have engaged others by granting them access to their personal health record.
  • 36% of the Program participants who use a computer to help manage their health utilize the library on the Network of Care website.
  • 43% of the Program participants who use a computer to help manage their health utilize health articles, interactive tools, forums, blogs or other social media or electronic resources.
  • 87.5% of the Program participants who granted others access to their Personal Health Record responded that those they granted access to found this beneficial.
  • 37.5% of the Program participants who granted others access to their Personal Health Record responded that their caregivers are now better able to coordinate their care needs.


Context of the Innovation: AIS, a division of the County of San Diego’s Health and Human Services Agency, has engaged health care and social service providers, aging and disabled consumers and advocates in improving health outcomes for older adults and persons with disabilities through systems integration and improved care coordination since 1999. AIS manages an annual budget of more than $300 million distributed across more than 30 programs.

In 2004 AIS received a grant from CMS and the Administration on Aging (AoA) through the California Department of Aging (CDA) to establish one of the first ADRCs in California. The AIS Call Center, which was established in 1999, was already an integrated service delivery model and gateway to all AIS programs and services. However, San Diego stakeholders recognized that a growing number of consumers, caregivers, health and social service providers, and family members were turning to the Internet to obtain information and support. In response to the needs of the community, a partnership was formed between the owner of the NoC website, Trilogy Integrated Resources Inc., and AIS. The NoC web resource was enhanced to include supports and components that weren’t available on other web sites. The impetus for enhancing CTI with the NoC and the electronic PHR came from wanting to increase the effectiveness of care transitions by utilizing web based technology to more fully engage patients at high risk for an avoidable readmission in their own care.

In 2008, AIS implemented TEAM SAN DIEGO, an award winning community health education initiative to address the need for improved chronic care coordination for patients served by the fragmented fee-for-service delivery system. The goal of TEAM SAN DIEGO is for multiple providers to work together as virtual teams through a patient’s PHR to improve access to comprehensive and coordinated health and social programs for individuals with complex health care and social service needs.

San Diego’s health care providers and community based organizations are highly engaged in improving the quality of care, improving patient’s experience with the health care delivery system, reducing readmissions and reducing health care costs through improved care transitions. San Diego is one of 17 Beacon communities nationwide and is the largest project funded. In November 2011, based on the outstanding outcomes from a CTI Pilot at Sharp Memorial Hospital, the San Diego Beacon Community supported the expansion of the CTI and the AIS Programs to two additional hospitals. AIS provided CTI and the electronic PHR to over 1,000 chronically ill patients.

Planning and Development Process:

Identifying and recruiting collaborating agencies: The Long Term Care Integration Project (LTCIP), which was established in 1999 and is comprised of more than 800 consumers, caregiver, advocates, health care and social service providers, served as the planning and implementation platform for the Program.

Educating health care staff: Engaging health care staff across the county in supporting patient activation through technology (the NoC) was vitally important to the success of the program. Trainings provided through the Program supported the creation of virtual teams to improve communication and care coordination for all providers involved in the care or support of chronically patients who are at risk for an avoidable readmission.

Resources Used and Skills Needed:

Staffing: Four AIS staff supported the Program including:

  • Project Manager (Aging Program Administrator) – 7% FTE
  • CTI Coach (Public Health Nurse) – 50% FTE
  • Project Analyst (Administrative Analyst) – 20% FTE
  • Technical Coordinator (Administrative Analyst) – 20% FTE

Costs: The program’s primary costs consist of salary and benefits for the AIS staff. There were additional operating expenses including supplies, communications, travel, and printing. Total program related cost was $99,000.


Getting Started With This Program: To successfully launch a technology-enabled care transitions program all of the following should be confirmed:

  • Funding to cover all costs associated with program delivery.
  • Internal organizational expertise in care transitions and established relationships with key stakeholders.
  • Proper targeting of program participants.
  • Ability to demonstrate added value for the organization.

Sustaining This Program: Recognizing the success of the CTI Program at Sharp Memorial Hospital, the San Diego Beacon Community funded further expansion of the program to serve over 1,000 chronically ill patients who are indigent, medically and socially complex, and are at high-risk for readmission at Sharp Memorial Hospital, Scripps Mercy Hospital, San Diego and UCSD Medical Center annually. Three certified Transition Coaches employed by AIS support the CTI Program at the three participating hospitals.

AIS continues to provide outreach to community health care and social service providers about the importance of patient activation and virtual teaming and about how both can be achieved through the NoC web resource.

Other Considerations and Lessons: Engaging chronically ill patients at the time of discharge in how to use technology that supports their transition to home is challenging. Patients can be overwhelmed or ill, have various service providers coming to their homes to provide care, and are tasked with scheduling follow up appointments with numerous health care providers. Patients are more receptive to adopting an electronic PHR months after their hospitalization.

Educating health care providers about how to use technology-enabled interventions to activate patients and support virtual teaming for improved communication and care coordination across providers is challenging due to limited staff time and competing staff priorities.

Tech4Impact Care Transitions Diffusion Grants Program