Transitions between settings
This guide offers advice and interventions that practices can use to help their patients reduce avoidable emergency department visits. It covers the following topics:
- Educating patients on appropriate use
- Enhancing access to the primary care practice
- Improving care coordination and care transitions
This guide, for hospital administrators and emergency department leaders, provides step-by-step instructions for planning and implementing patient flow improvement strategies to ease emergency department crowding.
The information and resources are organized into the following sections:
- The need to address emergency department crowding
- Forming a patient flow team
- Measuring emergency department performance
- Identifying strategies
This toolbox contains tools and strategies to assist health care professionals in implementing Always Events ® initiatives and meeting their patient- and family-centered care goals. Always Events ® are defined as “those aspects of the patient and family experience that should always occur when patients interact with healthcare professionals and the delivery system.”
These tools and strategies were developed by numerous health care professionals from...
This toolkit provides a step-by-step guide to improving the medication reconciliation process. It promotes a successful approach to medication management and reconciliation that emphasizes standardization of the process for doctors, nurses, and pharmacists within the facility to document and confirm a patient's home medication list on admission. It also emphasizes the need to clearly define roles and responsibilities of clinical staff.
The toolkit is based on the Medications at...
Developed for States, area agencies on aging, aging and disability resource centers, tribal organizations, and other local service providers within the National Aging Network, the Administration on Aging Care Transitions Toolkit is targeted to organizations that are interested in learning more about how to prepare their organization for a role in care transitions programs. It provides tools and resources to assist in developing partnerships with health care providers or programs that span...
Health care providers can use this toolkit during hospital discharge to help patients leave the hospital with confidence. It includes the tools and information patients need to make a smooth transition to their next destination.
Elements of the toolkit are:
- Staying Safe When You Leave the Hospital: A journal-like bifold booklet that guides patients and family members to collect their thoughts and ask the right questions.
- Talking to...
This guide for hospital leaders and administrators provides strategies to assess, prioritize, implement, and monitor efforts to reduce avoidable readmissions and reduce costs in the health care system. A four-step approach is presented as an approach to follow at different stages of the care. The four steps are:
- Examine your hospital’s current rate of readmissions
- Assess and prioritize your improvement opportunities
- Develop an action plan of strategies to implement...
INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.
The specific tools are designed for use by selected members of the care team. Some of the tools included are:
- Communication tools
The STate Action on Avoidable Rehospitalizations (STAAR) Initiative of the Institute for Healthcare Improvement and The Commonwealth Fund aims to reduce avoidable rehospitalizations and is focused on two components:
- A multistate learning community to improve transitions of care
- Targeted technical assistance to address systemic barriers to reducing avoidable rehospitalizations
The project Web site includes the following materials:
This toolkit has been designed for patient-centered medical homes aiming to transform how their clinics manage patient referrals and transitions, and its goal is to provide clinical practice resources to support coordinated care. The toolkit introduces four key concepts for enabling change, and offers activities, tools, and case studies to support their implementation.
The toolkit is divided into the following sections:
- The care coordination...