Transitional Care Provider or Agency Use? Services [Examples] Clinical and Behavioral Health Yes No Providers Community health centers, federally [ability to qualified health centers accept new patients; timely posthospital followup; social work, nutritional, pharmacy services, etc.] Accountable care organization with care [high-risk-care management or transition care management, transitional care to reduce readmissions, etc.] Medicaid managed care organizations [high-risk-care management, social work, wraparound services, etc.] Program of All-inclusive Care for the [capitated or Elder (PACE), Senior Care Options risk-bearing (SCO), Duals Demonstration providers providers focused on providing whole-person care to improve quality and reduce costs] Medicaid health homes [engagement, outreach, tiered care management; eligibility based on chronic and behavioral health conditions] Multiservice behavioral health centers, [prioritized including behavioral health homes posthospital followup; availability for new patients; co-located support services, etc.]
Provider or Agency Transitional Care Services [Examples] Use? Clinical and Behavioral Health Providers Yes No Community health centers, federally qualified health centers [ability to accept new patients; timely posthospital followup; social work, nutritional, pharmacy services, etc.] Accountable care organization with care management or transition care [high-risk-care management, transitional care to reduce readmissions, etc.] Medicaid managed care organizations [high-risk-care management, social work, wraparound services, etc.] Program of All-inclusive Care for the Elder (PACE), Senior Care Options (SCO), Duals Demonstration providers [capitated or risk-bearing providers focused on providing whole-person care to improve quality and reduce costs] Medicaid health homes [engagement, outreach, tiered care management; eligibility based on chronic and behavioral health conditions] Multiservice behavioral health centers, including behavioral health homes [prioritized posthospital followup; availability for new patients; co-located support services, etc.]