The Central Texas Aging, Disability & Veterans Resource Center (CTADVRC) provides the Central Texas Care Transitions Program (CTCTP). The program is an evidenced based, patient-centered program developed to reduce 30 day re-admissions to the hospital by empowering patients to become more involved in their healthcare management to facilitate safe transitions across care settings. The CTADVRC offers two evidence based care transition interventions. See below for a brief description of both:

Care Transition Intervention

  • Coach interacts with the patient four times over 30 days
    (In the hospital, at home, and two follow-up phone calls)
  • The Four Pillars of CTCTP
  • Medication review and safe management
  • Maintenance of a personal health record (PHR)
  • Recognition of “red flag” symptoms
  • Medical follow-up
  • Filling gaps in care after discharge
  • Reduction in preventable 30 days re-admissions
  • CTCTP patients determined to be at risk for re-admission to the hospital or SNF

Bridge Model Call Center

The Bridge Model is a short-term social worker-facilitated telephonic transitional care intervention. The Bridge Transition Coach has contact with the patient through 3 to 4 phone calls during a 30 day period. A home visit may be needed if a Bridge Transition coach determines it is necessary. The initial phone call includes a thorough social work assessment to address the bio-psychosocial factors that may challenge patients and their caregivers in their transition home. The Bridge Model emphasizes collaboration among hospitals, community-based providers and the Aging
Network in order to ensure a seamless continuum of health and community
care across settings.