Q&A: Care transition resources
Q. What resources can case managers use to improve transitions of care?
A. There are many evidence-based studies, pilots, and programs available to the case manager to guide him or her in assisting patients from hospital to home. The case manager as the expert in care transitions may be involved in developing guidelines for the population health model or may be a member of the implementation team. Some examples of projects that may help case managers better transition patients include:
- Project RED (Re-Engineered Discharge). This project is designed to prevent readmissions and transition patients safely from acute care to the community. It consists of a bundle of 12 discrete but complimentary components used at and during discharge. Follow-up appointments and postdischarge calls are important elements of Project RED.
- Transitional Care Model. Mary Naylor, PhD, FAAN, RN, at the University of Pennsylvania is credited with developing the Transitional Care Model. Naylor uses advanced practice nurses to transition patients from hospitals to home. The nurse is the practitioner, patient advocate, and case manager. The nurse follows the patient from the hospital into the home.
- Project Boost (Better Outcomes by Optimizing Safe Transitions). This national program was created by the Society of Hospital Medicine. It is a multidisciplinary initiative with a comprehensive playbook and a mentoring program for institutions who would like to implement the program.
For more information, see Case Management Guide to Population Health: Management Across the Continuum of Care.
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