Question special

Emergency departments, homeless shelters, ICUs, mobile vans--care happens in disparate settings for the underserved. Transitions between these care settings can be disjointed and (for the patient) disorienting. This contributes to and exacerbates health disparities for the underserved. Various models--intensive case managers, coaches, patient navigators, home-based primary care--have been trialed to improve care transitions. What models have you seen in action?