Coordinated-Transitional Care (C-TraC) for Veterans From Subacute Rehabilitation to Home.

Stephanie Denise M Sison, Joyanne John, Chi Mac,Marcus Ruopp,Jane A Driver

Journal of the American Medical Directors Association（2023）

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摘要

We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

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关键词

Post-acute care,telephone-based,nurse-led

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