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Redefining the future of health transitions

Meeting the complex health care needs of individuals living with chronic illnesses such as heart failure, diabetes and depression in a person-centered, safe, and efficient manner will be a, if not the, dominant healthcare challenge in the next few decades. Our research agenda focuses on the growing population of chronically ill adults with a specialization on frail, elderly adults and their family caregivers. Members’ implementation of various research methods is now creating a body of knowledge that will directly benefit this vulnerable population. 


‘Playbook’ to improve care for people with complex needs

The Playbook: Better Care for People with Complex Needs released today, jointly supported by five national health care foundations- The Commonwealth Fund, The John A. Hartford Foundation, the Peterson Center on Healthcare, the Robert Wood Johnson Foundation, and the The SCAN Foundation, in partnership with the Institute for Healthcare Improvement -is a free resource to health system leaders, insurers, policymakers and other stakeholders.

New roles nurses serving chronically ill patients

Southwestern Vermont Medical Center (SVMC) embarked on their Transitional Care journey in 2013 by redeploying and preparing acute care Clinical Nurse Specialists from the ICU, ED and Telemetry units.

Team collaboration at Northside

Nurses, pharmacists, social workers, respiratory therapists, physical therapists, dieticians and physicians collaborate daily to provide high quality care to COPD and PNA patients in their transitional care program.