Care Transitions Projects

The Institute for Health Policy and Practice (IHPP) has partnered with the NH DHHS and community-based organizations on a variety of care transitions grants and projects.

A man assists an elderly woman in a wheelchair.

Aging and Disability Resource Center Person-Centered Care Transitions

Previous grants included a focus on care transitions objectives to improve linkages between local hospitals and the ServiceLink Resource Centers (SLRC). IHPP formed a state level workgroup in 2009 with the goal of creating and implementing care transitions models in three New Hampshire communities. With this objective in mind, the work group was formed with representation from three chosen pilot area SLRCs, the pilot area community hospitals, person-centered planning experts, consumers, the NH-Hospital Association, the NH Home Care Association, and the EasterSeals Community Liaison project. In 2010, the group worked to adapt principles from the variety of care coordination/care transition/person-centered/patient-centered (and other) models to design a model for New Hampshire. An evaluation report was complete on the three pilot communities and assess the models. IHPP continues to provide technical assistance as needed to these:

Partnership for Care Transitions Workgroup

In 2009, a state-wide workgroup was formed under NH’s Aging and Disability Resource Center grants for evidence based care transitions models. The multi-stakeholder group informed the role of ServiceLink Aging and Disability Resource Centers transitions pilot projects in three NH communities with partner acute care hospitals. After the pilot ended, the workgroup evolved and continues to meet on a quarterly basis to discuss and collaborate on care transitions models being implemented throughout New Hampshire. Anyone is welcome to participate.  If you are interested in attending the Partnership for Care Transitions workgroup, contact Laura Davie.

Seacoast Collaborative Care Coordination Subcommittee

Under the umbrella of care transitions, IHPP worked with the Seacoast Collaborative, made up of a group of stakeholders in the Seacoast Region engaged in improving care coordination: Rockingham Community Action, Integrative Health Liasion, Appledor Medical Group, Child and Family Services, Seacoast Mental Health, SeaCare Health Services, Graf, Raulerson & Middleton Professional Association, Institute for Health Policy and Practice Portsmouth Regional Hospital, Parkland Medical Center, United Way of the Greater Seacoast, Foundation for Seacoast Health, United Way of the Greater Seacoast, ServiceLink Resource Center, Lamprey Healthcare, Two International Group, Crossroads House, Mark Wentworth Home, Families First. IHPP was involved in launching a pilot program to evaluate the utilization of a Common Referral Form between providers. The goal was to assess whether or not this will improve communications between providers.

Care Transitions Conference

IHPP, under the umbrella of CACL, partnered with the Northern New England Geriatric Education center to host a two-day conference focused specifically on care transitions models. The goals of the conference were to educate and foster collaboration among New Hampshire communities. This two-day event, held May 25 and June 15, 2011, was sponsored by the Endowment for Health, Administration on Community Living, and Dartmouth Hitchcock. Some of the conference participants went on to form care transitions collaboratives. Through CACL the Partnership for Care Transitions Workgroup still continues to meet (see above).