Facilitating Transitions II goes beyond the first module on this topic which was specifically constructed to address medical home related attributes as assessed by recognition and accreditation entities. This module addresses best practices in care transitions, including transition of at-risk populations, coordination with hospitals, home health care teams, and family members. Standardized communication formats and transition records are also highlighted.

A detailed listing of authors is here.

This module was made possible by funding from the American Board of Internal Medicine Foundation (ABIMF).

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