2207       Title: Transitional Care Date: Friday, June 20, 2008 Time: 02:30 PM - 04:00 PM Type: CONCURRENT Level: INTERMEDIATE Track: Integrated Care Sponsor(s): - Speaker(s): Polly K. Howard; Lisa S. LaChapelle The Transitional Care Program at Johns Hopkins Healthcare is an exciting new venture in Care Management. The population is our USFHP, retired military members, similar to a Medicare population. Transitional care is focused on transition points as a patient moves throughout the continuum of care. The transition points are defined as from home to hospital, hospital to nursing home for rehabilitation, or complex medical care, and from nursing home to home, long-term care, assisted living, or other care setting.  The program goals are to decrease LOS for our subacute facilities, earlier discharge planning and life care planning, and medication reconciliation across all settings. Interventions are geared towards collaboration with the patient and family, communication with the providers, increased patient and family satisfaction, and education concerning medication and benefit plan. All discharged members receive a phone call to assess knowledge level of discharge instructions, services expected, and follow-up appointments.  The model consists of highly experienced care coordinators with rehabilitation background and an assistant. The Care Coordinators visit the patients and develop a collaborative relationship with the nursing homes and staff. Patient safety, quality initiative, and improved satisfaction are all important parts of the Transitional Care program at Johns Hopkins Healthcare. Objectives: Outline the healthcare system fragmentation processes which result in poor transitions across settings.   Analyze the interventions for the Transitional Care program, including the SNF component and the Welcome Home component.   State the outcomes evaluation process.