Coach-led transitional care of elderlies in the United States:Intervention model / 中华医院管理杂志

This paper detailed the Coleman concept and practice of coach-led transitional care of elderlies,team members and their responsibilities,intervention aspects and main tasks,as well as the intervention program and its effect analysis.Then the authors analyzed the present transitional care development in China,and recommended on development of a likewise care model for senior chronic disease patients in the country,such as building multi-disciplinary transitional care teams to provide uninterrupted care and service,encourage patients and caregivers to embrace self-management of diseases,and build an appraisal mechanism to ensure quality of care.