CART2
An Interdisciplinary Team Approach to Improving Transition Across Sites of
Geriatric Care
(Care Transition Teams)
Funded by: The John A. Hartford Foundation
Project Period: 1/01 - 12/04
The overriding goal of this project is to improve care transitions across sites
of geriatric care. This will be achieved through a patient-centered
interdisciplinary team model that is comprised of four components: 1)
A patient-centered record that consists of the essential care elements for
facilitating productive interdisciplinary communication during the care
transition. 2) A structured checklist of critical activities designed to
empower patients to enlist interdisciplinary collaboration across the
transition. 3) A Geriatric Nurse Practitioner (GNP) led group activation and
self-management sessions designed to help patients and their caregivers
understand and apply the first two elements, and assert their role in managing
transitions. 4) GNP follow-up visit(s) in the skilled nursing facility or in
the home with accompanying phone calls designed to sustain the first three
components and provide continuity across the transition.
Key Staff: Coleman, Parry, Smith
Research Monographs:
Coleman EA, Kramer AM. "Interdisciplinary Models to Meet the Primary Care Needs of Older Adults." John A. Hartford Foundation. May 2000.
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