
Care navigators can help facilitate transitions as patients — particularly those with chronic or complex diseases — move from the acute care to home setting while remaining connected to needed outpatient services.

This set of resources will help to guide institutions toward building a CHW program to strengthen and sustain their health care workforce. Members only.
Podcast explores how Orlando Health is reaching outside its walls to meet the needs of moms who are at risk of experiencing cardiovascular issues.
Hear how Northwell Health seeks to decrease the incidence of preventable maternal morbidity and mortality in its community by focusing on care before conception, during pregnancy and through the “fourth trimester.”
A Transitional Care Program empowers patient to actively manage their care, to set individualized goals, and to make informed decisions while improving the patient experience, improving the health of the population and decreasing cost.
The Winona Wellbeing Collaborative focused its efforts on addressing the fragmentation and silos between agencies and providers via implementation of a community HUB model.
Peace Harbor Medical Center — a critical access hospital in Florence, Ore. — partnered with the local ambulance service to offer home visits as patients transition between care settings.
15 hospitals in North Carolina and South Carolina are implementing financially sustainable initiatives to improve the patient experience, enhance care coordination and decrease avoidable readmissions.