As moves between different levels of care, settings, and providers increasingly characterize the health and long-term-care experience of older adults, proper planning and management of care transitions has become an essential skill for social service practitioners who work with elders and their families. This timely course presents the various care-transition models that are known to decrease unnecessary hospitalizations, improve patient outcomes, and lower social and economic costs. Course participants will learn how to develop effective interventions to ease care transitions based on new methods and tools used by hospitals and community agencies throughout the country. (4 CEUs)
- Knowledge of (1) how care transitions relate to the care continuum; (2) the most common care-transition interventions and activities, and how these address the barriers to good care; and (3) the most commonly used evidence-based models.
- Understanding of the various roles of practitioners in relation to healthcare institutions and community-based organizations in transitional care.
- Skills to (1) communicate with other healthcare and social service team members; and (2) form relationships with clients and families, perform assessments, coordinate care, and assist in planning discharges and post-discharge follow-up.