Emerging Evidence-Based Care Transition Models

Several care transition models are emerging, supported by research and evaluation, that aim to improve coordination among health care providers and to help individuals better understand their post-hospital care. Some models emphasize the use of a nurse or nurse practitioner as a coordinating entity and others include social workers and other human services professionals as potential transitions coordinators. Other models utilize physician-led teams to help coordinate care for individuals. ADRCs can play important roles in implementing or facilitating these care transitions efforts in local communities across the country.

• Care Transitions Intervention
• Guided Care
• Transitional Care Model
• Geriatric Resources for Assessment and Care of Elders (GRACE)
• Better Outcomes for Older Adults through Safe Transitions (BOOST)
• The Bridge Program