Collaborating for a comprehensive care of older people with complex care needs emerges as interlacing the different threads of care to construct seamless. Webideal transition in care. Bridge created by burke et al. The framework recommends a number of domains that can be addressed to achieve seamless care transitions. This is a critical concern for health plans that. Webthe coordination of care as patients move from one health care setting to another is crucial to treatment, but breakdowns in the process lead to poor transitions, fragmented care,. Webin this whitepaper, we examine how a connected network can bridge the gap in data flow and align care approaches with the shifting needs of an aging population. Webin particular, this review will synthesise evidence that can guide the design of digital health interventions, improve the understanding of the role of technology in the. Webhome health care services can bridge this gap, but may be underutilized or unavailable. In this pilot project, we examined processes at the patient and organizational.
