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The Safe Transitions Project furthers Rhode Island's leadership around care coordination, already evidenced by the Continuity of Care Form. The project:
- Focuses on patients’ discharge from the hospital to other care settings,
- Promotes cross-setting communication, and
- Ultimately, aims to improve patients' transition experiences, self-management skills, and outcomes.
The project includes patient- and systems-level interventions focused on Medicare patients at high risk for re-hospitalization. These include:
- Providing in-hospital computerized education prior to discharge,
- Coaching patients for 30 days after discharge,
- Working one-on-one with home health agencies, hospitals, and nursing homes to implement best practices, and
- Fostering cross-setting communication.
The project also focuses on community engagement via a Leadership Advisory Board co-chaired by Drs. Brian Jack and Eric Coleman--eminent researchers whose work forms the basis of the computerized education and coaching interventions, respectively.
With questions about setting-specific interventions, please contact:
With general questions, or for more information about the project, please contact Lynne Chase, Program Administrator, at 401-528-3253.
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