Care Transitions

General Information:

Improving Care Transitions (Health Affairs/Robert Wood Johnson Foundation/September 2012) This brief describes the conditions that lead to poor care transitions, key elements to improving care transitions, and the policy issues around payment reforms to improve care transitions.
Aging and Disability Resource Centers Evidence-Based Care Transitions (DHHS, Administration on Aging/2011). This website describes several care transition models including BOOST, Bridge program, Care Transitions Intervention, Guided Care, and Transitional Care Model. Also provides resources for administrators and families.
Roadmap to Better Care Transitions and Fewer Readmissions (DHHS, Partnership for Patients/June 2011). This website will help providers and communities understand the processes of care transition and access helpful resources.
Guidance on Health Care Information Sharing (Pennsylvania Department of Public Welfare/March 2010). This tool is for health plans and providers to guide patient information sharing within federal and state laws and regulations.
Exchanging Information in Medicaid: Overview of Confidentiality Issues (Center for Health Care Strategies/April 2009). This presentation examines options states have for sharing health data among state agencies, health plans, and providers and explains when patient consent must be obtained.

Resources for Transitions from Hospital or Nursing Homes:

Dual Eligible Beneficiaries and Potentially Avoidable Hospitalizations (CMS/September 2011). This report examines the frequency of potentially avoidable hospitalizations and demonstrates that reducing the number of these hospitalizations among dual eligible beneficiaries could lead to improved quality of care and decreased spending.
Transitions of Care from Hospital to Home (Alliance of Community Health Plans and Avalere Health/April 2012). This report highlights promising approaches and key practices for improving care transitions employed by ACHP members.
STate Action on Avoidable Rehospitalizations (STAAR) (Institute for Healthcare Improvement/2012). The website provides an overview of the STAAR program that involves payers, stakeholders, caregivers, and health care providers to reduce hospital readmissions. The site includes a summary of program evaluation results and links to implementation tools.
Project Re-Engineered Discharge (Project RED) (Boston University Medical Center/2012). Project RED develops and tests strategies to improve hospital discharge processes. The website provides an overview of the Project RED intervention, as well as a training manual and toolkit to implement the intervention.
Interventions to Reduce Acute Care Transitions (INTERACT) (Florida Atlantic University/2011). INTERACT is a quality improvement program designed to improve identification, evaluation, and communication about changes in resident status to reduce transitions to hospitals. The website provides a program overview and related tools and educational resources.
Improving Care Transitions Between the Nursing Facility and the Acute-Care Hospital Settings (American Medical Directors Association/March 2010).This white paper addresses efficient transfer processes, highlighting key elements of successful approaches.
Transitions of Care in the Long-Term Care Continuum (American Medical Directors Association/2010). This clinical practice guideline provides recommendations for transitions in care across long-term care settings.
Improving Transitions of Care: How to Implement and Evaluate a Plan (Agency for Healthcare Research and Quality/2010). This website presents a quality improvement tool to help health care institutions in developing and implementing care transition processes.
Improving Transitions of Care: Findings and Considerations of the “Vision of the National Transitions of Care Coalition” (National Transitions of Care Coalition/September 2010). This report provides recommendations and links to resources to improve care transitions across health care settings.

Resources for Transitions to the Community:

Money Follows the Person (MFP) (CMS/2012). This website describes the Money Follows the Person Rebalancing Demonstration Program.
What Determines Progress in State MFP Transition Programs? (Mathematica Policy Research/October 2011). This study examines program elements crucial to progress in MFP transition programs.
Understanding Medicaid Home and Community Services: A Primer (DHHS, Office of the Assistant Secretary for Planning and Evaluation/October 2010) Chapter 6, “Transitioning People from Institutions to the Community” discusses general factors to consider, ways to prevent unnecessary hospital admissions and long stays, and how to establish an effective quality assurance system.
Integrating Care for Populations and Communities (Colorado Foundation for Medical Care/2010). This website includes materials developed as part of a Medicare Quality Improvement Organizations initiative to implement community-based projects to improve care transitions.

Forms to Facilitate Care Transitions:

Universal Transfer Form (American Medical Directors Association/2007). This form is used to facilitate communication of necessary information as patients transfer from one care setting to another.
CCITI NY Transfer Form (Continuum of Care Improvement through Information New York (CCITI NY)/2012). This form is used to improve patient transfers between acute, post-acute, and ambulatory care organizations in the greater New York area.
Continuity of Care Form (Rhode Island Department of Health). This form is used to communicate patient health information and facilitate transitions between health care settings.
Integrated Care Plan Template – Connected Care Pilot (UPMC Health Plan/2009). A web-based integrated care plan, developed for the Southwestern Pennsylvania Rethinking Care Program pilot, physical and behavioral health plans share data with care managers.

Care Transitions

TOOLKIT SECTIONS