An overview of the GRACE Team Care model for in-home assessment and care management of common geriatric conditions by a team of experts.

The Care Transitions Intervention® is also known as the CTI®, the Skill Transfer Model™, the Coleman Transitions Intervention Model® and the Coleman Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home.

A sample checklist for patients about to be discharged to ensure that they have a full understanding of their condition and what they need to do as a result. 

Examples and guidelines for promoting a healthy, positive outlook in patients with regards to their condition and treatment.

Guidelines and rationale for engaging the patient in the decision making processes related to their condition and care.

The health care experience is taxing and confusing for patients and their families. The complexity often leads to disengagement and poor adherence to the plan of care. The Bridge Model is designed to integrate into any health care system in order to address these issues.

Reducing readmission rates through improved care transitions requires an evidence-based approach that incorporates adequate communication, optimized workflows and institutional commitment to improving patient outcomes.