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RWJF Announces 'Transitions to Better Care' Video Contest Winners

Five innovative programs to reduce potentially avoidable hospitalizations through better care transitions can now be seen online as winners of the Robert Wood Johnson Foundation's (RWJF) "Transitions to Better Care" video contest

Patients, families, nurses, care coordinators, and other front-line healthcare providers were invited to submit videos telling their stories of how they help patients make successful transitions out of the hospital. More than 100 videos were submitted showcasing innovative, patient-centered approaches at transition points in care.

The contest is part of Care About Your Care, a month-long effort sponsored by RWJF to focus attention on the national problem of people returning to the hospital soon after they are discharged. 

Almost one in five elderly patients released from a hospital is back within 30 days and more than a third are back within 90 days. Many of these return visits could be avoided with better care transitions when a patient is discharged from the hospital.

The five winners will join Nancy Snyderman, MD, NBC News chief medical editor, and Risa Lavizzo-Mourey, MD, RWJF president and CEO, at a Care About Your Care event later this month in Washington, D.C., highlighting successful ways to improve care transitions and reduce avoidable hospital readmissions. The winners will receive special recognition from RWJF and a professionally produced video describing their innovation.

"These videos provide examples of how hospitals, doctors, nurses and other providers across the country are developing innovative ways to improve care for patients," says Anne F. Weiss, team director and senior program officer at RWJF. "The contest winners, and all those who participated, should be proud of the important work they are doing to effectively coordinate care with their patients and other providers."

The winners of the video contest are:

Cullman Regional Medical Center, Cullman, Ala. - A program called "Good to Go" ensures patients understand and comply with their discharge instructions by having caregivers record discharge sessions with their patients. The patient and family can listen to the captured conversation and ask questions to clarify confusion. Good to Go caregivers can also access instructional videos, baseline photos, appointment reminders, medication lists, and more from any phone or computer using secure login information. 

Mercy Health, Cincinnati, Ohio - At Mercy Health, nurses developed a system to evaluate patients and work collaboratively with other healthcare providers to provide them with the appropriate care. The team helps patients take ownership of their situations to help prevent readmissions.

Northern Piedmont Community Care, Durham, N.C. - Northern Piedmont Community Care developed a community-based care management system that provides transitional care, chronic disease management, social work services, service coordination, access support, health education, and nutrition counseling. The program, which focuses on those who are frequent users of the hospital, offers support and links patients to primary care and other services they need.

Queen of the Valley Medical Center, Napa, Calif. - The CARE Network (Case Management, Advocacy, Resource/Referral, Education) provides an interdisciplinary continuum of care from hospital to home followed by community-based chronic disease management support. The program works to improve health conditions and quality of life among patients and reduce healthcare costs through better coordination, continuity of care, timely enrollment, and access to public assistance programs and community services.

University of Utah Health Care, Salt Lake City, Utah - The Health Care Transitions Program developed the Transition Navigator role to provide direct follow-through for complex patients being discharged from the hospital. The Transition Navigator communicates with the hospital and primary care teams to bridge the gap and ensure continuity of care. They work closely with patients to make certain they have a clear understanding of their plan and provide additional support through a personal care manager.

Submissions were evaluated on the quality of the story and method of ensuring safe transitions, potential for replication, and an element of engaging the patient in the hospital discharge process.

RWJF will convene dozens of national and grassroots organizations for a Care About Your Care event in Washington, DC, to discuss how healthcare leaders in communities and hospitals can best coordinate care for patients leaving the hospital. The event will be simulcast live on Feb. 13 at 12:30 p.m. EST.

To learn more about the Care About Your Care effort, visit

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