Transitions of Care

Transitions of Care Models

ModelAuthor/Ownership of ProgramProgram FocusTransitions FacilitatorsLength of InterventionPatient EducationMedication ManagementFollow UpPersonal Health Record
Care Transitions Intervention (Coleman Model)Eric Coleman, MD
University of Colorado
Hospital-Community Organization TeamsTransition Coaches4 weeksXXXX
Transitional Care Model (Naylor Model)Mary Naylor, PhD, RN
University of Pennsylvania
Hospital to HomeAPNs serve as Transitional Care Nurses (Trialing Bachelor’s Prepared Nurses)1-3 monthsXXX
BOOST (Better Outcomes for Older Adults)Society of Hospital MedicineHospital to HomeNo explicit care coordinator30 daysXXXX
GRACE (Geriatric Resource for Assessment)University of IndianaPrimary Care Physician OfficeNurse Practitioner and Social WorkerLong TermXXXX
The Bridge ProgramIllinois Transition ConsortiumHospital to Home/CommunityMaster’s Prepared Social Workers30 daysXXX
Project RED (Re-Engineered Discharge)Boston UniversityHospital to HomeDischarge Advocates (Testing Virtual Advocates)Not specifiedXXX