| 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 |
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