Connect-Home: Transitional Care in Skilled Nursing Facilities

Transitional care is a set of time-limited services to ensure coordination and continuity of care as patients transfer between settings and providers of care. This chapter describes the Connect-Home transitional care intervention designed for skilled nursing facility (SNF) patients and their caregivers. Seven topics are covered: challenges of care transitions in SNFs, Connect-Home transitional care, the role of SNF interdisciplinary teams in Connect-Home, the efficacy of Connect-Home, care of diverse populations, implementation strategies and outcomes, and value-based payment in SNFs.