Key to the development of care transitions programs is the understanding of the changes in reimbursement that led to their creation. We will briefly discuss this backdrop for the development of a care transitions program. A variety of care transitions models that have been piloted will be presented. The benefits that have been demonstrated through research will be reviewed. This leads us into an overview of the reasons for developing a collaborative care transitions program and a discussion of who should be involved in such an endeavor for it to be successful. Finally, a case study of a collaborative care transitions program will be used as an illustration.
Home care is one of the largest growth industries in healthcare today. With changes in hospital reimbursement, home care provides services that are tailored to keep people in their home and community. Nurses are the key providers of home care services. RNs, LPNs and home health aides provide different levels of services, which are individualized to meet the patients' needs. Services are reimbursed in a variety of ways, depending on the patient's type of insurance, age and diagnoses. Home care agencies can be licensed and certified, or operate independently, but may not qualify for insurance reimbursement. The type of organization will dictate, in part, the staffing choices the organization makes.