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21. Defining the PCMH | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/ncepcr/research/care-coordination/pcmh/define.html
    August 01, 2022 - is particularly critical during transitions between sites of care, such as when patients are being discharged

22. CAHPS Nursing Home Survey: Family Member Instrument (doc file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/nursing-home-family-eng-1652a.doc
    September 01, 2011 - Was your family member discharged from this facility or did he or she die? … 1 FORMCHECKBOX Discharged ( If Discharged, Stop Here.

23. AHRQ Health Literacy Tools for Use in Pharmacies | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/health-literacy/improve/pharmacy/tools.html
    January 01, 2024 - Top of Page How To Conduct a Postdischarge Followup Phone Call Calls to patients newly discharged

24. Learning Outcomes Assessment | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps/lep/handouts/leputcomesasst.html
    December 01, 2012 - Lo is ready to be discharged. Mr. Khang worries that Mr.

25. TeamSTEPPS Limited English Proficiency Module: Learning Outcomes Assessment (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/lep/handouts/leputcomesasst.pdf
    July 25, 2012 - Lo is ready to be discharged. Mr. Khang worries that Mr.

26. Dailygoals (doc file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/cusptoolkit/toolkit/dailygoals.docx
    January 01, 2003 - Note Changes From AM in This Column Safety What needs to be completed for this patient to be discharged

27. Tool: Advocacy and Assertion | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps-program/curriculum/mutual/tools/advocacy.html
    June 01, 2023 - final treatment, reviews the clinical situation, and determines that the patient is well enough to be discharged

28. CAHPS Nursing Home Survey: Family Member Instrument (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/surveys-guidance/nh/nursing-home-family-eng-1652a.pdf
    September 01, 2011 - Was your family member discharged from this facility or did he or she die? … 1 Discharged → If Discharged, Stop Here.

29. Designing and Delivering Whole-Person Transitional Care: The Hospital Guide to Reducing Medicaid Readmissions - Toolbox (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/medread-tools.pdf
    July 28, 2016 - to home (without home health) % of discharges discharged with home health % of discharges discharged … to SNF readmissions. 50% 40% 30% 20% 10% 0% home health % of discharges discharged to … to home (without home health) Readmission rate among patients discharged to SNFs % of readmissions … An exclusive focus on improving transitional care for patients discharged to home may not be data … A focus on patients discharged to SNF (or any postacute care) is data informed.

30. AHRQ's RED Toolkit Helps Lower Readmissions in Dignity Health Hospitals | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/news/newsroom/case-studies/201522.html
    August 01, 2015 - Patients who are discharged home receive a follow-up phone call within 72 hours" as well as three additional

31. TeamSTEPPS® Instructor Manual: Specialty Scenarios | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps/instructor/scenarios/ambulatory.html
    October 01, 2014 - Johnson is discharged with instructions to call the office the next day if he is still having problems … Johnson is discharged, the Troponin I level of 0.22 (normal <0.03), indicating myocardial ischemia, is

32. Re-Engineered Discharge Toolkit (pdf file)
    pcmh.ahrq.gov/sites/default/files/publications/files/redtoolkitforms.pdf
    September 01, 2012 - Our records show that you were recently a patient at {name of hospital} and discharged on {date of discharge

33. Event Investigation and Analysis Guide: Appendix B | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/hospital/candor/modules/guide4/apb.html
    August 01, 2022 - Smith discharged home.

34. Introducing the CAHPS Cancer Care Survey (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/cahps-cancer-care-yost.pdf
    June 13, 2017 - off on active data collection for the Cancer Care Survey until 51 days after the patient has been discharged

35. TeamSTEPPS Specialty Scenarios: Ambulatory Care (pdf file)
    pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/scenarios/ambulatory.pdf
    March 19, 2014 - Johnson is discharged with instructions to call the office the next day if he is still having problems … Johnson is discharged, the Troponin I level of 0.22 (normal <0.03), indicating myocardial ischemia,

36. Daily Goals Checklist | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/hai/cusp/toolkit/daily-goals.html
    December 01, 2012 - Changes From AM in This Column   Safety   What needs to be completed for this patient to be discharged

37. RED Discharge Preparation Workbook (pdf file)
    pcmh.ahrq.gov/sites/default/files/publications/files/dischargeprep.pdf
    February 14, 2013 - RED Discharge Preparation Workbook 1 RED Discharge Preparation Workbook Patient Name _________________________ MRN ________________ DOB ______________ Room # ______________ Date of admission ______________ Language preference Interpreter/Translation Needed (Y/N) Spoken communication Writt…

38. Scoring Different Kinds of Health Care Quality Measures | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/talkingquality/translate/scores/scoring.html
    June 01, 2016 - patients admitted to a hospital with a heart attack received a prescription for a beta blocker when discharged

39. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
    January 01, 2024 - develop an automatic notification system to alert physicians of final test results after a patient is discharged

40. Webinar 6: Enhance Services for High-Risk Patients | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/patient-safety/settings/hospital/resource/guide/web6.html
    December 01, 2017 - Patients discharged to short term skilled nursing facilities. … including the following criteria: live alone, no source of emotional support, no support system in place, discharged