Increasingsupport forpatientsandcaregiversat the hospital andthroughtheir transitionbackhome.

Patient navigator, RoShawndaThompson, at bedside discussing transportation options with heart failure patient, Celane Brewer.

PArTNER is a transitional care model for Minority-Serving Institutions (MSIs) that aims to increase support to patients and caregivers at the hospital through their transition home. The PArTNER transitional care model strengthens the bridge between hospital and home by adding two supports— a community health worker acting as a patient navigator and a peer coach via a telephone support line.

Patient navigator, EmmaVillarreal, on a home visit to a participant after discharge from the hospital

PCORI IH-12-11-4365 | 2013—2018

Phone-based peer coaching provided by:

Uzma Kazmi, a research coordinator, enrolled participants in the program.

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