This implementation of the CTI, with its flexible design responsive to the diverse needs of patients, hospitals, and community organizations, provides a host of real-world lessons on how to improve and sustain effective patient transitions between care settings. Healthcare systems interested in improving care transitions have a compelling reason to explore the viability of implementing the intervention with attention to developing or addressing the following: strong care transitions leadership; collaborative hospital-community partnerships; the particular needs of diverse communities; patient-level medication reconciliation and management; and tailoring the model to the unique needs of patients with cardiovascular conditions and diabetes.

BACKGROUNDImplementing Physician Orders for Life Sustaining Treatment (POLST) forms aims to improve communication of life-sustaining treatment preferences across care venues. California enabled this clinical tool in 2009, and a novel intervention of community coalitions was undertaken to advance POLST in localities around the state. Coalitions engaged facilities, including nursing homes (NHs), to foster POLST adoption. Eighteen months after introduction of POLST, we studied POLST implementation in California NHs.METHODSNHs randomly selected in coalition and non-coalition areas were mailed surveys about POLST preparation and use in 2010. Coalitions identified which NHs they worked with.RESULTSOf 546 NHs surveyed, 143 (52 %) in coalition areas and 141 (52 %) in non-coalition areas responded. In 82 % of responding NHs, staff received POLST education and 59 % of NHs reported having a formal policy on handling POLST. Two-thirds of NHs had admitted a resident with a POLST, and 15 % of newly admitted residents over the past month had a POLST (range 0–100 %). Eighty-one percent of NHs had completed a POLST with a resident. Fifty-four percent of residents were estimated to have a POLST (range 0–100 %) (coalition area NHs 60 % vs. non- coalition area NHs 48 %, p = 0.02). Within coalition areas, NHs that had worked with coalitions were more likely to have completed a POLST with a resident after admission than NHs that had not worked with coalitions. Few NHs (7 %) reported difficulty following POLST orders, but 38 % noted difficulty involving physicians in POLST completion.CONCLUSIONLess than 2 years after introduction, many California nursing homes report using POLST, although some NHs reported no experience. A novel community coalition intervention facilitated POLST implementation.Electronic supplementary materialThe online version of this article (doi:10.1007/s11606-012-2178-2) contains supplementary material, which is available to authorized users.