Transitions between settings


Taking Care of Myself: A Guide for When I Leave the Hospital 06/15/10

This guide for patients can help them care for themselves when they leave the hospital. The easy-to-read guide can be used by both hospital staff and patients during the discharge process and provides a way for patients to track important information, such as:

  • Medication schedules
  • Upcoming medical appointments
  • Questions they may have
  • Important phone numbers
  • Notes about their medical problem
Next Step in Care: Family Caregivers and Health Care Professionals Working Together 01/21/10

Next Step in Care: Family Caregivers and Health Care Professionals Working Together is a campaign that provides information and advice to help family caregivers and health care providers plan safe and smooth transitions for patients when patients move from one care setting to another. Resources are available in English, Spanish, and Chinese.

Topics covered include:

  • For family caregivers
    • Guides for all caregivers
    • Hospital stay and discharge planning...
Care Notebook 08/20/09

The Care Notebook is a tool for families of children with special health care needs to organize information about their child’s chronic health condition. The notebook contains sections that can be filled out as a reference about the child’s health and treatments. It is a transportable tool that can be taken and shared with doctors, other health care professionals, or school or child care personnel.

Parents can use the Care Notebook for the following:

  • ...
Improving on Transitions of Care: How to Implement and Evaluate a Plan 06/10/09

This guide helps health care institutions develop and implement processes for sending and receiving patients from one care setting to another. The information and plans provided allow institutions to measure their performance in transitions of care and identify areas for improvement.

Topics covered are:

  • Introduction
  • Background
  • Evaluating and improving transitions of care in your institution
  • Nursing home to emergency department (ED)/...
Your Discharge Planning Checklist: For Patients and Their Caregivers Preparing to Leave a Hospital, Nursing Home, or Other Care Setting 06/10/09

This patient handout can help patients, caregivers and medical staff communicate as they prepare to leave a hospital, nursing home, or other health care setting. The booklet provides many questions and prompts for patients and caregivers so they can gather information to assure a safe discharge.

Envisioning My Future: A Young Person's Guide to Health Care Transition 06/09/09

This guide, written for youth with special health care needs, helps them prepare for their transition from pediatric health care or service to adult care or service. The guide provides tips for the young person, their parents, and family; transition checklists; and other information to help young patients adjust to the new setting and assure a safe changeover.

Topics covered include:

  • About transition
  • New responsibilities (ages 12-14)
  • Practicing...
Adolescent Health Transition Project 06/07/09

The Adolescent Health Transition Project is designed to help smooth the transition from pediatric to adult health care for adolescents with special health care needs. This site is a resource for information, materials, and links for people interested in health transition issues.

Site contents include:

  • Information for:
    • Teens and young adults
      • Diabetes-specific information
    • Parents and families
      • Diabetes-specific information
      • ...
BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions Resource Room 10/01/08

The BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions Resource Room provides a wealth of materials to help hospitals optimize the discharge process.

These tools can help to:

  • Analyze current workflow processes
  • Select effective interventions
  • Redesign workflow and implement interventions
  • Educate your team on best practices
  • Promote a team approach to safe and effective discharges
  • Evaluate your...
Strategies to Improve Handoffs 07/11/08

This tool provides an outline of recommended strategies to improve the handoff process in hospitals (i.e., patient transitions in care from one provider to another). It provides a description of each of the following strategies as well as resources to assist in developing an implementation plan:

  1. Consider different types of handoffs and places where they occur
  2. Standardize handoffs–reduce variation
  3. Map the handoff process
  4. Employ six principles of error-...
Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure 03/19/08

Transforming Care at the Bedside is a national program designed to improve the quality and safety of patient care on medical and surgical units, to increase the vitality and retention of nurses, and to improve the effectiveness of the entire care team.

This how-to guide includes the following information:

  • Four key components of an ideal transition home and individual changes that can be tested
  • A practical step-by-step sequence of activities to assist staff in...


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