Topic: Healthy Aging: Enhancing Care Transitions

Presenters: Kelsey Boersma, MPH, Allan Kozlowski, Ph.D., & J’nise Ramsey, MBA, MS, ATC, Mary Free Bed Rehabilitation Hospital

Description: Despite study of interventions to facilitate patients’ return from hospital to home following stroke, many patients, and their care partners experience difficulty with care transitions. Reported interventions tend to focus on immediate needs, such as managing self-care, transfers, and medication management but do not address return to social participation. To better assist in preparation for transition from hospital to home or in navigating recovery during the transition this presentation will allow rehabilitation clinicians to gain knowledge in ongoing research of an intervention focused on return to participation and of a novel case management intervention. The Integrated Access Program, Introduction to the Care Transitions Model, and the MI-CHAP (Michigan Changes Healthy Aging Program) including implementation and successes will also be presented.

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