Care Transitions: Evidence-Based Best Practices for Case Managers
Mary D. Naylor, PhD, FAAN, RN
- Identify individual/family and system factors associated with poor post-discharge outcomes among hospitalized older adults;
- Illustrate the context for transitional care in everyday practice across health care settings;
- Identify key findings from testing of the Transitional Care Model and describe the core components of the model; and
- Describe the impact of the evidence supporting the Transitional Care Model on clinical practice and health care policy recommendations.