Transitions of Care Models

Model Author/Ownership of Program Program Focus Transitions Facilitators Length of Intervention Patient Education Medication Management Follow Up Personal Health Record
Care Transitions Intervention (Coleman Model) Eric Coleman, MD
University of Colorado
Hospital-Community Organization Teams Transition Coaches 4 weeks X X X X
Transitional Care Model (Naylor Model) Mary Naylor, PhD, RN
University of Pennsylvania
Hospital to Home APNs serve as Transitional Care Nurses (Trialing Bachelor’s Prepared Nurses) 1-3 months X X X
BOOST (Better Outcomes for Older Adults) Society of Hospital Medicine Hospital to Home No explicit care coordinator 30 days X X X X
GRACE (Geriatric Resource for Assessment) University of Indiana Primary Care Physician Office Nurse Practitioner and Social Worker Long Term X X X X
The Bridge Program Illinois Transition Consortium Hospital to Home/Community Master’s Prepared Social Workers 30 days X X X
Project RED (Re-Engineered Discharge) Boston University Hospital to Home Discharge Advocates (Testing Virtual Advocates) Not specified X X X