- 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:
Resources for Transitions to the Community:
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.