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For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
Transition of Care \u2013 The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility.
Coleman's Four Pillars philosophy to avoid rehospitalizations. By using the Four Pillars, we empower patients and families with the knowledge they need to accomplish their goal of staying safely in their home.

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Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patient's potential needs at the time of admission and continues throughout the patient's stay.
Transition of Care \u2013 The movement of a patient from one setting of care (hospital, ambulatory primary care practice, ambulatory specialty care practice, long-term care, home health, rehabilitation facility) to another.
TCPs are designed to provide short term, low intensity, restorative care to older adults (aged 65+) who are medically fit to leave the hospital but are unable to do so due to multiple issues including hospital acquired deconditioning and lack of social supports in the community [3].
Transitional Care Planning is a patient-centered, interdisciplinary process that begins with an initial assessment of the patient's potential needs at the time of admission and continues throughout the patient's stay.
The Coleman Model. The Coleman Care Transitions Intervention (CTI) is a four-week process designed to empower and support patients to take a more active role in their health care.

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