Lesson 5: Care Coordinating and Care Navigation
Care Transitions Program
The Care Transitions Intervention is a 4-week program where patients with complex care needs and family caregivers receive specific tools and work with transitions coach, to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.
Center for Disease Control, 2011.
This free online course is intended to increase understanding among public health and aging services professionals about key issues related to advance care planning for end of life, including communicating and documenting one’s wishes and preferences.