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.
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.
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.
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.
Presented by the Center for Disability and Aging Policy (CDAP), the Administration for Community Living is an evidence-based care transitions program.
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.
Reports and Articles
Policy paper on care transitions: Best practices and evidence-based programs.
To improve patient transitions from one care setting to another, CHCF funded the implementation of the Coleman Care Transitions Intervention in 10 California communities.
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.
Part of the "Always Use Teach-Back" toolkit, this sheet give pointers on effective teach-back communication.
Tools and Guides
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.
A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.
Red Flag Tools for Patients
Zone Tools Asthma (English) Zone Tool Asthma (Spanish)
Zone Tool COPD (English) Zone Tool COPD (Spanish)
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