Partnerships for Community Health

Care Transitions Resources

The Centers for Medicare & Medicaid Services (CMS) defines a transition of care as the movement of a patient from one setting of care to another. Settings of care may include hospitals, ambulatory primary care practices, ambulatory specialty care practices, long-term care facilities, home health, and rehabilitation facilities. Transitions increase the risk of adverse events due to the potential for miscommunication as responsibility is given to new parties. Hospital discharge is a complex process representing a time of significant vulnerability for patients. Safe and effective transfer of responsibility for a patient’s medical care relies on effective provider communication with patient comprehension of discharge instructions. (AHRQ Care Coordination Chartbook)

CARE TRANSITION MODEL RESOURCE GUIDE
This compendium identifies external care transitions resources by care setting(s), key points and estimated time commitment for implementation if applicable. Care settings noted are those in which the resource was implemented and/or researched. Most can be used in other settings. Use the comparison table to jump to a resource, or scroll through the resource descriptions below.

Resource	Inpatient/ Hospital	Outpatient/ Clinic/ED/ Urgent Care	SNF/ Long-Term Care	Home Care
ASPIRE Guide and Toolkit	X
CARE – Continuity Assessment Record and Evaluation Item Set	X		X	X
Care Transitions: Best Practices and Evidence-Based Programs	X	X	X
Care Transitions Program Toolkit	X	X
Care Transitions Toolkit	X	X	X	X
Community-Based Care Coordination Toolkit	X	X	X	X
Designing and Delivering Whole-Person Transitional Care	X	X
Expanded Rooming and Discharge Protocols	X	X
Health Literacy & Health Equity Toolkit	X	X	X	X
Health Equity in Readmissions Guides	X	X
IDEAL Discharge Planning	X			X
IMPACT Act Reporting and Assessment	X		X	X
Improving Medication Safety in High-Risk Medicare Beneficiaries Toolkit	X	X
MARQUIS Implementation Manual: A Guide for Medication Reconciliation Quality Improvement	X
Medication Safety in Transitions of Care	X	X	X	X
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit	X	X	X
Hospital Transfer Self-Assessment Worksheet for Nursing Homes			X
Project Boost Implementation Guide to Improve Care Transitions	X
Project Red (Re-engineered discharge) Toolkit	X
Readmissions Change Package	X
RARE – Reducing Avoidable Readmissions Effectively	X	X	X	X
SafeMed Model Care Transitions Training Module	X	X	X	X
Social Needs Screening Toolkit	X	X	X	X
STAAR – STate Action on Avoidable Rehospitalizations How-to Guide	X	X	X	X
Transitions of Care Toolkit for Critical Access Hospitals	X	X	X	X
TST – Targeted Solutions Tool	X	X	X	X

 

ASPIRE Guide and Toolkit (Agency for Healthcare Research and Quality – AHRQ)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

The six steps in this guide to reducing Medicaid readmissions (Analyze data, Survey current readmission efforts, Plan Multifaceted Strategies, Implement Whole-person care, Reach out and collaborate with Cross-Continuum Providers, Enhance Services for high-risk patients) make up the acronym ASPIRE to help hospital teams remember and implement the full structure of this framework.
Key Points:

• Target population Medicaid
• Focus on data-informed decision making
• Discusses whole-person approach to care transitions, clinical, behavioral and social lens

Estimated Time Commitment for Implementation: Extensive toolkit, may take six months or more to implement.

 

CARE – Continuity Assessment Record and Evaluation Item Set (CMS)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care   Home Care

This report determines the differences in Continuity Assessment Record and Evaluation (CARE) patient assessments between provider types, across acute care hospital and post-acute care settings: skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), home health agencies (HHAs), and long-term care hospitals (LTCHs).
Care Assessment Tools:
Discharge 
Expired
Home Health Admission
Institutional Admission
Video Reliability Testing

 

Care Transitions: Best Practices and Evidence-Based Programs (Center for Healthcare
Research & Transformation)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care   Home Care

This paper summarizes best practices in care transitions and describes successful programs that
reduced readmissions and overall costs and includes an annotated bibliography detailing the research on care transitions and descriptions of the care transitions programs offered by the University of Michigan Health System and Blue Cross Blue Shield of Michigan.

 

Care Transitions Program Toolkit (Eric A. Coleman, MD, MPH)
Care Setting(s):
Inpatient/Hospital   Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care Home Care

This toolkit is designed to assist patients and their family members with hospital discharge planning and self-advocacy. Easy to use tools and checklists including the Family Caregiver Activation in Transitions (FCAT), Care Transitions Measure (CTM) and Hospital Specification tools help patients, families and caregivers navigate discharge from hospital, improve quality and manage risk during care hand-overs.

 

Care Transitions Toolkit (Partnership for Patients, Alaska State Hospital and Nursing Home Association, Washington State Hospital Association)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This toolkit provides assessment and communication tools and recommended care transition processes for emergency department visits and inpatient admissions for skilled nursing homes.

 

Community-Based Care Coordination Toolkit (Stratis Health)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care Home Care

The Community-based Care Coordination (CCC) Toolkit provides tools for use at different stages in the development of a CCC program — including how to begin. Tools focus on people, functions, policy, and processes to achieve success in the community-based care coordination environment.

Estimated Time Commitment for Implementation: Full implementation: 26 weeks; Individual components: Immediate

 

Designing and Delivering Whole-Person Transitional Care (AHRQ)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This guide and toolkit focuses on Medicaid population and community discharge support and includes a community resources guide and cross-continuum tool that helps with developing linkages to the clinical, behavioral and social service provider.

 

Expanded Rooming and Discharge Protocols (American Medical Association)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

Expanded rooming and discharge protocols address inefficient workflows by organizing and standardizing common tasks that the practice team performs during patient visits. The strategies in this learning module will enable practices to create personalized patient rooming and discharge checklists to increase patient and staff satisfaction with the care being provided.

 

Health Literacy & Health Equity Toolkit (Minnesota Health Literacy Partnership)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

These resources help connect the dots between health literacy and health equity.
Health Equity & Health Literacy Key Messages and Talking Points
Health Equity & Health Literacy infographic

 

Health Equity in Readmissions Guides (CMS, Michigan Hospital Association)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

These guides contain key recommendations to follow across settings using various tools and examples of initiatives using these strategies with a focus on resources and reducing readmissions among diverse populations.
Eliminating Disparities to Advance Health Equity and Improve Quality (MHA)
Guide to Reducing Disparities in Readmissions (CMS)

 

IDEAL Discharge Planning (AHRQ)
Care Setting(s):
Inpatient/Hospital   Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This hospital-to-home discharge planning handbook contains downloadable tools and checklists and follows the IDEAL discharge planning strategy (Include the patient and family as partners in the discharge planning process, Discuss with the patient and family the key areas to prevent problems at home, Educate the patient and family in plain language, Assess how well doctors and nurses explain the diagnosis, condition, and next steps through teach-back and Listen to and honor the patient and family’s goals, preferences, observations, and concerns).
Tools and checklists download

 

IMPACT Act Reporting and Assessment (CMS)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

Information and reporting tools for the IMPACT Act, which mandates the collection and reporting of standardized data in post-acute care settings, including resources and requirements of the standardized patient assessment data elements (SPADEs).
Data Standardization & Cross Setting Measures
Setting-Specific Reporting Tools:
Long-Term Care Hospitals (LTCHs)
Skilled Nursing Facilities (SNFs)
Inpatient Rehabilitation Facilities (IRFs)
Home Health Agencies (HHAs)
Standardized Patient Assessment Data Elements (SPADEs)

 

Improving Medication Safety in High-Risk Medicare Beneficiaries Toolkit (AHRQ)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care   Home Care

This toolkit was developed based on the study Medication Evaluation and Drug Use Problem Identification to Improve Safety in High-Risk Medicare Beneficiaries (MEDIS-MB). The MEDIS-MB was a randomized controlled trial that was designed to evaluate the effects of an ambulatory-based medication therapy management (MTM) program for the elderly on patient safety measures. The toolkit includes forms and tools designed for the delivery and assessment of MTM programs.

 

MARQUIS Implementation Manual: A Guide for Medication Reconciliation Quality Improvement (Society of Hospital Medicine – SHM)
Care Setting(s):
Inpatient/Hospital   Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This manual is a compilation of best practices and a common process of medication reconciliation with tools – adaptable to the environment and setting, including community engagement, social marketing for patients and providers and discharge medication reconciliation counseling.
Companion Resources:
Best Possible Medication History (BPMH) Train the Trainer Materials

Key Points:

• Decrease medication errors and adverse drug events during times of care transitions.
  

Estimated Time Commitment for Implementation: Does not specify but gives 12-month examples.

 

Medication Safety in Transitions of Care (World Health Organization)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This report contains key strategies for improving medication safety during transitions of care including leadership and improvement programs: formal structured processes, workforce capacity and capability, partnering with patients and families and improving information quality, availability and measurement.

 

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit (AHRQ)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This step-by-step guide to improving medication reconciliation processes as patients move through the health care system includes tools to develop a flowchart of your current medication reconciliation process and build a foundation for your medication reconciliation process design.

 

Hospital Transfer Self-Assessment Worksheet for Nursing Homes (AHRQ)
Care Setting(s):
Inpatient/Hospital   Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

The Hospital Transfer Self-Assessment Worksheet can help nursing home staff identify and review the care that they provide that may lead to avoidable transfers to the hospital or emergency department.

 

Project Boost Implementation Guide to Improve Care Transitions (SHM)
Care Setting(s):
 Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This guide aims to influence the discharge process beyond reducing readmissions by tailoring the toolkit to the unique needs of each organization. The toolkit outlines clear steps including organizational commitment, assembling the team, clarifying key stakeholders, assessing current state, project planning/goal setting, choosing key performance indicators, and implementing the toolkit via a small test of change.

Estimated Time Commitment for Implementation: 12-24 months.

Companion Resources:
The PArTNER model guide
PATient Navigator to rEduce Readmissions (PArTNER) is a transitional care model for Minority-Serving Institutions (MSIs) that aims to increase support to patients and caregivers at the hospital through their transition home.

 

Project RED (Re-engineered discharge) Toolkit (AHRQ)
Care Setting(s):
 Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This toolkit is designed to help hospitals improve discharge processes to reduce readmissions and posthospital emergency department visits, particularly those that serve diverse populations.

Estimated Time Commitment for Implementation: 12 months or longer.

 

Readmissions Change Package (American Hospital Association, Partnership for Patients, HRET Health Research & Educational Trust)
Care Setting(s):
 Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This resource pulls together several change packages with a variety of tools to reduce hospital readmissions, including RED, BOOST, STAAR, Care Transitions Model and AHRQ med reconciliation. The package contains methodology, ideas and several tools to assess patient risk and evaluate improvement progress.

Estimated Time Commitment for Implementation: Three years.

 

RARE – Reducing Avoidable Readmissions Effectively (ICSI, MHA, Stratis Health)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This resource provides recommendations that are core strategies for improvement. These recommendations based on best practice, evidence and consensus are key practices that organizations should be working to implement to reduce avoidable hospital readmissions

 

SafeMed Model Care Transitions Training Module (American Medical Associaton)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This training module teaches the SafeMed care transitions model, which was designed with primary care in mind and relies on primary care-based team members, including physicians, pharmacists, nurses, and community health workers, to form a support network for high-risk/high-needs patients as they transition from the hospital to outpatient setting.

 

Social Needs Screening Toolkit (Health Leads)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This screening toolkit can be utilized in a variety of care settings and is intended to identify social needs that may impact a person’s overall health and wellness.

 

STAAR – STate Action on Avoidable Rehospitalizations How-to Guide (Institute for Healthcare Improvement)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This guide was developed to reduce rehospitalizations by working across organizational boundaries and by engaging payers, stakeholders at the state, regional and national level, patients and families, and caregivers at multiple care sites and clinical interfaces.

 

Transitions of Care Toolkit for Critical Access Hospitals (Montana Rural Hospital Flexibility (Flex) Program)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This toolkit was designed to be used internally by Montana critical access hospitals in conjunction with members of the MBQIP 2 Outcomes performance improvement project. This tool can be used in parts or as a whole in order to meet hospital-specific needs. The toolkit is divided into four color-coded categories: Regulatory, Assessments and Evaluations, Communication and Data.

 

TST – Targeted Solutions Tool (Joint Commission Center for Transforming Healthcare)
Care Setting(s):
Inpatient/Hospital  Outpatient/Clinic/ED/Urgent Care  SNF/Long-Term Care  Home Care

This online tool measures the effectiveness of hand-offs within your organization or to another facility and provides evidence-based solutions to increase patient and family satisfaction; staff satisfaction; and successful transfers of patients.