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You can find a full complement of care coordination assets in the main Care Coordination section.
A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.View Resource
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.View Resource
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.)View Resource
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