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Mid-State Health Center: PATT Project

  • Project Title: Plymouth Area Transitions Team (PATT)
  • Grant Period: 05/01/2012-04/30/2015
  • Contact Name: Sharon Beaty, CEO
  • Location: New Plymouth, New Hampshire
  • Program Overview: The goal of this program, run by the Mid-State Health Center, is to address care transitions and reduce hospital readmissions for patients with complex health needs, as well as to improve quality and reduce costs of care. PATT is modeled off of three transition of care program models – Project BOOST, Care Transitions Intervention, and the Transitional Care Model. A transitional care manager is used to work with the patient and caregiver on education and developing an appropriate care plan. The transition manager will also follow up with the patient both at-home following discharge and then weekly by telephone for 30 days. During this time, the transition manager also provides assessments, patient and family education and continued support. In addition, this program provides coordinating inter-agency services to identify potential problems, partnerships with home health agencies and transportation services to continue to reduce barriers faced in rural New Hampshire.

Read about the Plymouth Area Transitions Team (PATT) Program in RHIhub's Rural Health Models and Innovations.

Models represented by this program: