Care Transition Initiatives

All of the Aging Service Access Points (ASAPs) have attained training in the Care TransitionsSM Program - a program aimed at improving patient outcomes when transitioning between providers or care settings, such as from a primary care physician office to an inpatient hospital ward to a skilled nursing facility.  Each "transition" can be problematic, as communication breakdowns, duplication of effort, and other inefficiencies can cause patients harm, or further exacerbate the threat of their condition.  It can also lead to wasting resources and inconveniencing patients and their families through unnecessary hospitalizations.  For more information on the program, please visit www.caretransitions.org
 
Through the training, individuals can become certified Care Transitions CoachSM: as the program states, coaches "model and facilitate new behaviors and communication skills for patients and families to feel confident that they can successfully respond to common problems that arise during care transitions. [The Coach] provides information and guidance to the patient and/or family for an effective care transition, improved self management skills and enhanced patient-practitioner communication."
 
Currently, the ASAPs have over one hundred trained coaches: each individual ASAP has no fewer than two trained coaches on its staff.
 
The Mass Health Data Consortium recently held a Care Transitions Forum: its meeting supplies may be found at http://mahealthdata.org/CareTrans.
 
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Jesse DeHond,
Dec 6, 2010, 12:46 PM
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Jesse DeHond,
Dec 6, 2010, 12:47 PM
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Jesse DeHond,
Dec 6, 2010, 12:46 PM
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