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25 <br />Objective D-2: Improve the coordination of care through increased contact and <br />training of health care and community care providers that are key <br />to the transitioning process. <br />Lead Organization j~Dept. on Aging with Partners-Carol Woods Center of Excellence, <br />and others. <br />Strategies: <br />A. Establish a Transitions Community Workgroup that meets regularly to discuss, <br />create and implement strategies to improve transitions.. <br />B.. Offer transitional care training of providers (and patients and their family members) <br />to improve transitions. (Examples may include trainings and resource listings for <br />discharge planners, including where to find nursing home survey reports, and a <br />caregiver brochure outlining suggestions for a smooth transition.) <br />Objective D-3: Improve the coordination of care through the development of <br />uniform transitional care informational forms, materials and <br />resources. <br />Lead Organization (s): Triangle J Area Agency on Aging with Partners-Dept. on Aging, <br />UNC Program on Aging and other regional aging providers. <br />Strategies: <br />A. Identify what health information is currently available, analyze haw to best use the <br />information, and explore how to coordinate and share information to enhance the <br />transitions and care of older persons, <br />B. Consider reinstituting a "Transfer Informaticn Sheet" for hospital, nursing home and <br />community transitions. <br />25 <br />