This module will define transitional care, identify gaps in transitional care and risk factors for readmission, and outline the roles of the Interprofessional Team in transitional care. Learners will be able to describe the 4Ms of an age-friendly health system, identify the eight care services associated with improved patient outcomes, and apply techniques that improve patient education. 

Audience: Discharge Planner

Care of Older Adults in the Long-Term Care Setting (COA-LTC) is a series created by the Hartford Institute of Geriatric Nursing (HIGN) at NYU Rory Meyers College of Nursing, in partnership with ArchCare, the Continuing Care Community of the Archdiocese of New York. The program was created to assure that all healthcare team members have the knowledge to care for older adults in long-term care settings. The program promotes team-based, coordinated, person-centered, evidence-based care for older adults.