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How would I apply the 4 pillars of the Care Transition Model (By Eric Coleman) that include 1- medic

How would I apply the 4 pillars of the Care Transition Model (By Eric Coleman) that include 1- medic. Question
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Asked by juliecook2015

How would I apply the 4 pillars of the Care Transition Model (By Eric Coleman) that include 1- medication self-management, 2- dynamic patient-centered health record, 3- primary care & specialist follow up, 4- and knowledge of red flags??

This patient is over 70 years. she had recent hip surgery, lives with a husband who has dementia, she is constipated, has chronic pain, very limited income, hx of heart failure, dehydration. She does not want her family to know in fear of being placed in nursing. She is aware that she could die but regardless does not want to leave her home.

How do I apply these principles to this situation?

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How would I apply the 4 pillars of the Care Transition Model (By Eric Coleman) that include 1- medic

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