Background of transitional care
This model of care focuses on interdisciplinary teams, long term goals, & works well with managing long term health conditions.
What is Chronic Care Model?
Engagement, wellness management, and integration
What are the three dimensions of transitional care?
This form of care delivers support to patients using practitioners who have lived experience.
What is peer support?
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What is UMSL?
This care model supports patients as they move from one level of care to another.
What is transitional care?
This stage of care involves establishing a relationship with a patient and learning about the patient's long term plans for their care.
What is engagement?
This is a community based approach to support patients.
What is Aggressive Community Treatment?
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This method of developing treatment plans focuses on the patient, their values, and their long term goals.
What is person centered care planning?
This dimension of transitional care focuses on developing skills to help patients manage their conditions.
What is wellness management?
This time based intervention focuses on supporting individuals who are in and out of hospitals and focuses on skill building, transitioning to the community, and transferring care.