The Community-Based Transitions Model: one agency's experience.

Home care providers have more than a century of experience providing complex patient care and medication management, symptom management, and disease self-management. These requisite home care clinician skills are common to those described of the "health coach" in most contemporary care transition models. When home care clinicians are re-tooled with health coaching competencies such as motivational interviewing, their role as the "perfect" health coach can be readily demonstrated. The Community-Based Transitions Model™ (CBTM) was developed by home care providers to equip clinicians with these additional skills and to address gaps in all care transitions along the chronic condition trajectory. This agency's experience with this model is described.