Links
- Partnership for Patients
- Integrating Care for Populations and Communities National Coordinating Center
- CMS Community Based Care Transitions Program
- Care Transitions Coach Intervention (Dr. Eric Coleman's Model)
- Transitional Care Nurse (Dr. Mary Naylor's Model)
- National Transitions of Care Coalition
- Society of Hospital Medicine - Project Boost
- Project RED - Re-Engineering Discharge
- Institute for Healthcare Improvement - Transforming Care at the Bedside
- Improving Chronic Illness Care - The Chronic Care Model
- Patient Centered Medical Home
- Guided Care
- American Academy of Family Physicians - the Medical Home Model
- MOLST (Medical Orders for Life Sustaining Treatment) Program
- Keeping Patients at Home (home health)
- Institute for Healthcare Improvement State Action for Avoidable Re-Hospitalizations (STAAR) Initiative
- Hospital to Home (H2H) Campaign
- Home Health Quality Initiative (HHQI)
- Patient Activation Measure