Care Transitions

Links, Resources and Tools

Care Coordination Quarterly - Current Edition
Care Coordination Quarterly - Archive

AHRQ Patient Safety Culture Surveys
CMS: Are you a hospital inpatient or outpatient?
Caregiver Information from Medicare
HRET - Health Care Leader Action Guide to Reduce Avoidable Readmissions

Interventions & Tools: Hospitals          Order Materials

Patient Personal Health Record (English)
Patient Personal Health Record (Spanish)
Free consumer tool! Download and add your provider stamp/message to the back cover. (Note: Cover may be subject to copyright restrictions.)
Patient Personal Health Record (English) (Word version)

Planning for Your Discharge Checklist (English)

Planning for Your Discharge Checklist (Spanish)
The Centers for Medicare & Medicaid Services has prepared this list for patients and their caregivers preparing to leave a hospital, nursing home or other care setting.
Order copies here. (Request Publication Number 11376)

AMA Video: Health Literacy and Patient Safety: Help Patients Understand (23 minutes)

Ask Me 3: Good Questions for Your Good Health

Physician Orders for Life-Sustaining Treatment (POLST)

POLST Offers Next Stage in Honoring Patient Preferences

Transitions of Care - Special Interest Group
The vision of the Transitions of Care special interest group is that all patients admitted to Georgia hospitals will receive the necessary tools and information that will prepare them for care after the hospital stay. This community-wide organization is sponsored by the Partnership for Health and Accountability of the Georgia Hospital Association. The members of the special interest group come from a wide base of providers within the state of Georgia.

Heart Failure Zones Tool - Green, Yellow, Red

Creating an Ideal Transition Home

Focus on Caregiving - Avoiding Hospitalizations
Provider - February 2009
Early identification and clinical best practices are key factors in averting hospitalization of nursing facility residents.

National Transitions of Care Coalition (NTOCC)
The National Transitions of Care Coalition (NTOCC) was formed in 2006 bringing together thought leaders, patient advocates, and health care providers from various care settings dedicated to improving the quality of care coordination and communication when patients are transferred from one level of care to another. This site offers information and resources for patients, health care professionals and policy makers. NTOCC Newsletter

Care Transitions Intervention Web site
Under the leadership of Dr. Eric Coleman, the aim of the Care Transitions Program is to support patients and families, increase skills among health care providers, enhance the ability of health information technology to promote health information exchange across care settings, implement system level interventions to improve quality and safety, develop performance measures and public reporting mechanisms, and influence health policy at the national level.

Colorado Foundation for Medical Care - Care Transitions Theme Web Site
This Web site supports the 14 Quality Improvement Organizations across the nation that will implement Care Transitions projects in select communities. Care Transitions focuses on patient-centered care that empowers Medicare beneficiaries to knowledgeably move through care settings.

How-to Guide: Creating the Ideal Transition Home for Patients with Heart Failure
This How-to Guide builds upon relevant research and published literature, and integrates what Transforming Care at the Bedside (TCAB) hospitals have learned as they strive to dramatically improve the quality of care for patients discharged from the hospital to home or to another health care facility.

Project RED: Re-Engineering Discharge
This project re-engineers the workflow process and improves patient safety for patients from a network of Community Health Centers discharged from a general medical service at an urban hospital serving a low-income, ethnically diverse population. The "Re-engineered Hospital Discharge" (Project RED) intervention provides a set of 11 discrete, mutually reinforcing components provided by a Discharge Advocate and re-enforced by a telephone call after discharge by a clinical pharmacist.

Project BOOST: Better Outcomes for Older Adults through Safe Transitions
The Society of Hospital Medicine launched Project BOOST to improve care of older patients as they transition from the hospital to home or another care facility. The project uses a team approach to assess patients’ risk for re-hospitalization and plan and execute risk-specific discharge planning activities. This site offers a comprehensive resource room, covering planning, best practices, education resources and clinical tools.

IHI Improvement Tracker

The Institute for Healthcare Improvement (IHI) has created an Improvement Tracking Tool that we strongly recommend you use in tracking the success of your interventions. The tracker is preloaded with standard defined measures in several topic areas, and it also allows you to create your own custom measures. After selecting or creating your unique measures, you set your aims and enter your data. The Tracker will create graphs and reports to show your progress on each measure.

Interventions & Tools: Nursing Homes

INTERACT II
Working Together to Improve Care and Reduce Acute Care Transfers

INTERACT II PowerPoint Presentation
INTERACT II Conference Call

INTERACT: Interventions to Reduce Avoidable Hospitalization of Nursing Home Residents
Disease Specific SBAR Communication
CNA Stop and Watch Assessment
Disease Specific Care Paths
Advance Care Planning
Unplanned Transfer Assessment

Go to MedQIC > Care Transitions

Interventions & Tools: Home Health Agencies & Hospices

Resources related to the following topics may be found at MedQIC:

Disease Management
Fall Prevention
Hospitalization Risk Assessment
Immunization
Medication Management
Patient Emergency Plan
Patient Self-Management
Phone Monitoring and Frontloading Visits
Physician Relationships
Telemonitoring
Teletriage
Transitional Care Coordination

Overview
Background
Provider Benefits
Patient Benefits
Resources & Tools

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