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Care Coordination

Provider Provider in Home with Senior Patients

Additional Resources

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You can find a full complement of care coordination assets in the main Care Coordination section. 

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BOOST - Better Outcomes by Optimizing Safe Transitions

A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.

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RED - Re-Engineered Discharge

The RED intervention is founded on 12 discrete, mutually-reinforcing components and has been proven to reduce rehospitalizations.

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The Care Transitions Program

Targeted for those who are discharged from hospital to home and provides a Transition Coach who focuses on medication self-management, the patient-centered medical record, follow-up appointments, and red flags. Transition Coaches can be incorporated into home health agencies’ model of care.

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Transition to Nursing Home How-To Guide

This guide, developed by the Institute for Healthcare Improvement (IHI), focuses on the transfer of residents from the hospital to the nursing home setting and the associated transfer of responsibility between the care teams. (Nursing home is an umbrella term that includes skilled nursing facilities, long-term care facilities, acute rehabilitation facilities, and post-acute care facilities.)

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