This session describes a transitional care model that effectively integrates a nurse practitioner across the Mount Sinai Hospital and Emergency Department, Internal Medicine Practice, and the Visiting Nurse Service of New York (VNSNY) Home Care. Medical home and idealized design concepts, a microsystem approach to system integration, key measures, and the primary care role in a transition model will be presented.
      After this presentation you will be able to:

Learning Objectives:
1. Describe a transitional care model that aims to effectively integrate a nurse practitioner across hospital, internal medicine practice, and home care settings.
2. Identify medical home and idealized design concepts that inform transitional care strategies across health care settings.
3. Discuss a microsystem approach to design a cross-setting transition care strategy that aims to reduce avoidable hospitalizations.