Project Description:
This project builds on current collaborative work between the NH Institute for Health Policy and Practice (NHIHPP), the ServiceLink Resource Centers (SLRC), and three local hospitals to implement and/or enhance evidence-based models for care transitions. Through this project, three SLRC which are part of the New Hampshire ADRC network, will work with two care transition models. The Better Outcomes for Older Adults through Safe Transitions (BOOST) model is currently being implemented at Lakes Region General Hospital (LRGH) in partnership with the Belknap SLRC. This work will be enhanced through the establishment of a care transition specialist (CTS) at the Belknap SLRC, who will work directly with LRGH to enhance how the BOOST model extends to the community. The Care Transition Intervention (CTI) model will be implemented at Cheshire Medical Center- Dartmouth-Hitchcock Keene (CMC-DHK), in partnership with Monadnock SLRC; and at Memorial Hospital, in partnership with Carroll County SLRC. Both the Monadnock SLRC and Carroll County SLRC will hire a SLRC CTS to provide resources for implementing the CTI model in those hospital-SLRC partnerships.
The primary program goals of the project are 1) Establish and train an SLRC -CTS in three of NH?s ADRC?s to serve as the SLRC-hospital liaison for care transitions 2) Define and evaluate the relationship of the SLRC CTS with the provider organizations in an evidence-based care transition model and 3) Define and evaluate the role of the SLRC CTS within the scope of the evidence-based care transition model and among SLRC programs (e.g. I/R specialist).
