Care Transitions: Evidence-Based Best Practices for Case Managers


Mary D. Naylor, PhD, FAAN, RN

Learning Objectives:

  • 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.