Helping Hospitals Improve Care Transitions for Patients


The Duke Endowment’s care transitions initiative is in an early phase, but project leaders say they’re already seeing hospitals implement best practices through the program.

Early insights include:

  • Designing the care transitions program with input from a broad and diverse group of stakeholders from both Carolinas was critical. The group included representatives from the state hospital associations, public and private payers, health care providers, the North Carolina Alliance for Effective Care Transitions (NC ACT), and South Carolina Preventing Avoidable Readmissions Together (SC PART).
  • Ongoing data collection is essential to tracking progress and implementing continuous quality improvement. Information gathered through a shared data portal will help track compliance with evidence-based standards.
  • A series of measures have been identified. They include increased use of standardized assessment of patients’ risk for readmission; more patients receive appropriate transition services tailored to their level of risk; increased patient confidence; and improved health of patients discharged from hospitals.
  • Technical assistance teams, formed through the North Carolina and South Carolina hospital associations, are providing collaborative learning opportunities, coaching calls and site visits to each hospital.
  • In addition to quantitative data, a survey will help assess each hospital’s efforts toward improving community engagement and developing partnerships.


Area of Work

  • Quality and safety of health care

Program Area

  • Health Care

Grantmaking Status

Areas of Work

  • Prevention and early intervention for at-risk children

    To equip children and families with skills to ensure that children reach developmental milestones to lead successful lives.

  • Out-of-home care for youth

    To drive child welfare systems toward greater accountability for child well-being.

  • Quality and safety of health care

    Improving the quality and safety of health care delivery

  • Access to health care

    Improving health by increasing access to comprehensive care

  • Prevention

    Expanding programs to promote health and prevent disease

  • Academic excellence

    Enhancing academic excellence through program and campus development

  • Educational access and success

    Increasing educational access and supporting a learning environment that promotes achievement

  • Campus and community engagement

    Promoting a culture of service, collaboration and engagement among schools and communities

  • Rural church development

    Building the infrastructure and capacity of United Methodist churches to enhance ministry and mission

  • Clergy leadership

    Strengthening United Methodist churches by improving the quality and effectiveness of church leadership

  • Congregational outreach

    Engaging United Methodist congregations in programs that serve their communities