This webinar will provide an introduction to transitional care and highlight a new care transition model developed by Oregon Health and Sciences University that targets low-income and uninsured patients, including those who are experiencing homelessness. Transitional care models aim to improve health care delivery, increase patient self-management skills, and reduce health care costs by preventing avoidable hospital readmissions. Improvements in care transitions are a mandatory component in the Affordable Care Act’s health homes initiative and are being adopted across the country as part of several other health reform programs. Communities implementing care transition programs face a number of obstacles including inadequate funding to support provider time, the absence of shared electronic records, and poor patient health literacy. Care transitions for people experiencing homelessness have added challenges such as limited access to recuperative care options, disproportionate rates of mental illness and addiction, and medical complications that arise from housing instability. Presenters will describe steps involved in building community collaboration and program implementation.
- Honora Englander, MD; Assistant Professor of Medicine, Medical Director, Care Transitions Innovation (C-Train); Oregon Health and Science University
- Meg Devoe, MD; Instructor of Medicine, Oregon Health and Science University
- Sabrina Edgington, MSSW; Program and Policy Specialist, National Health Care for the Homeless Council; Nashville, Tennessee