Post-Acute Care Transitions

Post-acute transitional care is designed to ensure the coordination and continuity of health care as patients transfer from hospital to home or related settings. Lack of appropriate care can result in re-hospitalization, duplication of services, inappropriate or conflicting care recommendations, medication errors, patient/caregiver distress, and higher costs of care. Model care transition interventions focus on improving the care transitions process, providing direct patient support, improving self-management capabilities, and increasing access to needed information and tools. Several types of technologies are being used to support post-acute care transitions (PACT) interventions. These technologies include those that can assist in improving medication adherence; medication reconciliation; patient monitoring; exchange of patient information; communications between and among clinicians, patients, and informal caregivers; risk assessment; and other important aspects of care transitions. Findings drawn from Center programs suggest that use of such technologies can lead to fewer hospitalizations and emergency room visits, high patient satisfaction and acceptance, and reductions in cost of care.

Tech4Impact Care Transitions Diffusion Grants Program