In the Community-Based Care Transitions Program, community-based agencies provide coaching and education to patients as they make the transition from hospital to home. Complementing this "high-touch" approach are a number of technology solutions developed by firms such as North Carolina–based Axial Exchange, Illinois-based Care Team Connect, and California–based Engineered Care that educate patients, track their progress after discharge, and identify gaps in care.

Axial Exchange recently won a Health 2.0 developer challenge that required engineers to build a system that would improve care transitions by easing the transmission of medical data among care settings and educating patients on ways to manage their conditions.

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Topics: Axial in the News, Care Coordination, Health Literacy, Hospital Readmission, Patient Engagement

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