Care Coordination

Discharge Checklist

A Target Heart Failure discharge checklist tool.

Discharge Criteria

Discharge criteria for patients hospitalized with heart failure.

CCTP Sites

Find Community-based Care Transitions Programs (CCTP) in your state, created by Section 3026 of the Affordable Care Act, which test models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries.

National Transitions of Care Coalition

The National Transitions of Care Coalition (NTOCC) provides tools and resources to patients, caregivers, healthcare professionals, and policy makers who seek to address challenges in meeting the needs of patients transitioning between care settings.

8Ps Risk Assessment Tool

From the Society of Hospital Medicine, this screening tool helps to identify a patient's risk for adverse events after discharge and screens for (1) problems with medications, (2) psychological issues, (3) principal diagnosis, (4) physical limitations, (5) poor health literacy, (6) patient support, (7) prior hospitalizations, and (8) palliative care.

BPIP Medication Management Package

The Best Practice Intervention Package (BPIP) includes a successful medication management program that encourages providers to work across settings, uses an interdisciplinary approach, and applies patient-centered teaching methods. This focused BPIP provides patient-friendly tools to improve health literacy and includes a tool and resource guide as well as a clinician guide.

Note: The Home Health Quality Improvement (HHQI) website requires registration to access this document.

Administration for Community Living

Presented by the Center for Disability and Aging Policy (CDAP), the Administration for Community Living is an evidence-based care transitions program.

Alliance for Home Health Quality and Innovation

The alliance examines ways in which home health care providers can improve the transition of a patient from acute care to post-acute home health care or from home health care to other settings.

Center for Healthcare Research and Transformation

Policy paper on care transitions: Best practices and evidence-based programs.

Coleman Care Transitions Intervention

To improve patient transitions from one care setting to another, CHCF funded the implementation of the Coleman Care Transitions Intervention in 10 California communities.

Always Use Teach-Back

The purpose of this training toolkit "Always Use Teach-Back," found at www.teachbacktraining.org, is to help healthcare providers learn to use teach-back to support patients and families throughout the care continuum, especially during transitions between healthcare settings. The toolkit combines health literacy principles of plain language and using teach-back to confirm understanding, with behavior change principles of coaching to new habits and adapting systems to promote consistent use of key practices.

Always Use Teach-Back 10 Elements of Competency for Using Teach-Back Effectively

Part of the "Always Use Teach-Back" toolkit, this sheet give pointers on effective teach-back communication.

Administration for Community Living

ADRCs have been working to assist individuals in “critical pathways,” defined as the times or places when people make important decisions about long-term care.

BOOST - Better Outcomes by Optimizing Safe Transitions

A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.

Asthma (English/Spanish)

Zone Tools Asthma (English) Zone Tool Asthma (Spanish)

Chronic Obstructive Pulmonary Disease (English/Spanish)

Zone Tool COPD (English) Zone Tool COPD (Spanish)