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Transitions of Care

(Updated January 12th 2017)

Transitions of Care refers to care directed at making a smooth transition between levels of care and/or care settings. Several transition care programs and services have been developed and implemented in an effort to improve quality, reduce the cost of health care, and reduce hospital readmissions.

Patient-Centered Medical Homes conduct interventions such as post-hospital discharge follow-up phone calls within 24-48 hours and scheduling a return visit with the primary care physician within 5 to 7 days. The call ensures patients are contacted by someone they know and whom they have an established relationship.

Webinars and Presentations

MiCMRC Educational Webinar

May 11 2016

To receive a certificate of completion Click Here.

Webinar replay video

Presented by

Della Slavsky RN, BSN, BA MiPCT Clinical Lead Upper Peninsula Health Plan

Janet Pund, BSN, RN-BC MiPCT Clinical Lead University of Michigan Health System

MiPCT Pediatric Care Management Webinar

Nov 21 2014

To receive a certificate of completion Click Here

Presented by

Linda Fletcher, MS, CPNP

Tools

Tools

Transition of Care Roles

Helps identify team members involved with transitions of care

Tools

LACE Tool

LACE Index Scoring Tool for Risk Assessment of Hospital Readmission

Tools

Transitional Care Model

From University of Pennsylvania School of Nursing. Naylor, M. Overview of the Transitional Care Model

Website

Website

IHI Transition of Care Resources