Community Assets Supporting Transitions (CAST)

"Intervention duration is expected to be 6 months. A full-time registered nurse (RN) will function as a Care Transitions Coordinator (CTC) who works collaboratively with one local hospital and other health and non-health representatives to deliver the intervention, which includes:~* care coordination and system navigation (including facilitating timely primary care follow-up);~* medication management;~* assessing the needs and risk of the participants (including in-depth assessment of depressive symptoms);~* evidence-based management of depressive symptoms and other chronic conditions to prevent the onset and worsening of other chronic conditions;~* patient and caregiver education; and goal setting and problem-solving therapy."