Healthcare leaders and providers have been addressing the gaps and barriers to transitions of care for over 20 years, yet we are still struggling to make significant impact not only for providers but patients and their family caregivers. This session will look at what we have put into place to address the issues and what is working to improve not only the quality of transitions but the satisfaction with the process for patients and their family caregivers. Case managers play a definite role in addressing the transitions and care coordination but getting that message out is still a challenge.

OBJECTIVES:

1. Review the gaps and barriers to improving transitions of care.
2. Assess the impact the COVID-19 pandemic has had on transitions of care
3. Define major models of transitions of care that have shown improvement to system processes, reduction of avoidable rehospitalization and managed the cost of care