Plan patient visits that focus on prevention and care management

Educate family members on available communication programmes and resources according to patients’ care needs to aid in recovery post discharge

Support caregivers or significant others in patient care

Provide tailored education and skills training using materials appropriate for different cultures and health literacy levels to prepare patients and caregivers for post-discharge care

Assess patients who require transitional care management for continuity of care

Develop comprehensive care plans

Coordinate care between settings to support care continuity

Review care transition plans

Assess ability of family towards self- management

Identify early signs of deterioration and institute early interventions to avoid hospital admissions

Monitor health outcomes

Refer patients to community programmes and resources to aid in recovery

Set key performance indicators for transitional care management programmes

Develop transitional care management approaches, frameworks or guidelines in collaboration with expert panel or professional organisations

Introduce innovative strategies in transitional care management to achieve desired outcomes

Lead the appropriate implementation of up-to- date technologies to enhance effectiveness of transitional care management programmes