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1. TFC6: Transition Record Contents (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/overall-charts.pdf
   June 02, 2025 - TFC6: Transition Record Contents Av er ag … 19 N ov 20 19 D ec 20 20 J an 0 20 40 60 80 100 0 85 100 TFC6: Transition … 20 19 N ov 20 19 D ec 20 20 J an 0 10 20 30 40 0 12.9 40 TFC6: Transition

2. TFC6: Transition Record Contents (pdf file)
   www.ahrq.gov/sites/default/files/wysiwyg/pqmp/toolkits/tfc6-allsites.pdf
   January 01, 2020 - TFC6: Transition Record Contents … TFC6: Transition Record Contents

3. Lost in Transition | PSNet
   psnet.ahrq.gov/web-mm/lost-transition
   November 17, 2010 - Lost in Transition. PSNet [internet]. … Lost in Transition. PSNet [internet]. … Two human-transition issues arise. … they become transition leaders. … Lost in Transition. PSNet [internet].

4. Transition to Nowhere | PSNet
   psnet.ahrq.gov/web-mm/transition-nowhere
   March 21, 2009 - Transition to Nowhere Citation Text: Farrell TW. Transition to Nowhere. … Transition to Nowhere. PSNet [internet]. … From the provider perspective, barriers to an effective care transition often include poor knowledge … , and activation of a transition management team led by an outpatient care manager. … Transition to Nowhere. PSNet [internet].

5. Heart-Failure-Transition-Care Executive (pdf file)
   effectivehealthcare.ahrq.gov/sites/default/files/related_files/heart-failure-transition-care_executive.pdf
   May 01, 2014 - authorized by the Affordable Care Act.6 This policy provides incentives for hospitals to develop effective transition … home health, outpatient followup), and symptom monitoring or reinforcement of education during the transition … No clear consensus exists about when the transition period ends. … chronic HF disease management, gaps remain in knowledge about effective interventions to support the transition … care, MDS-HF); home visits; telemonitoring (including remote clinical visits); telephone support; transition

6.  Develop Transition Plan - Jim Blakely (pdf file)
   hcup-us.ahrq.gov/db/ccr/ip-ccr/CCR_NIS_UserGuide_2001-2019.pdf
   January 01, 2019 -  Develop Transition Plan - Jim Blakely HCUP (9/2/2021) -1- User Guide: CCR for NIS Files, 2001-2019

7. Heart-Failure-Transition-Care Clinician (pdf file)
   effectivehealthcare.ahrq.gov/sites/default/files/pdf/heart-failure-transition-care_clinician.pdf
   October 01, 2015 - Transitional Care Interventions To Prevent Readmissions for People With Heart Failure Focus of This Summary This is a summary of a systematic review evaluating the evidence regarding the efficacy, comparative effectiveness, and harms of transitional care interventions (defined in Table 1) that aim to reduce readmiss…

8. A Seasonal Care Transition Failure | PSNet
   psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
   June 01, 2016 - A Seasonal Care Transition Failure Citation Text: Young JQ. … A Seasonal Care Transition Failure. PSNet [internet]. … A Seasonal Care Transition Failure. PSNet [internet]. … symptoms.( 12-14 ) This potentially heightened acuity makes monitoring even more critical during the transition … A Seasonal Care Transition Failure. PSNet [internet].

9. children-special-needs-transition-protocol-131003 (pdf file)
   effectivehealthcare.ahrq.gov/sites/default/files/pdf/children-special-needs-transition_research-protocol.pdf
   October 01, 2013 - Examples of transition models include the use of a separate clinic for transition activities, a phased … the effectiveness of transition models. … Description of the context for implementing transition care a. … What are the resources needed to implement transition care? c. … Center (Got Transition?)

10. Recurrent Hypoglycemia: A Care Transition Failure? | PSNet
    psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
    December 23, 2020 - SPOTLIGHT CASE Recurrent Hypoglycemia: A Care Transition Failure? … Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. … Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. … Even better, the presence of a true EHR would have markedly facilitated the transition of care from the … Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet].

11. e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-enhanced-care-transition-support-complex
    January 01, 2023 - e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients … The Care Transition Intervention (CTI) was developed to address this problem. … The care transition nurses called patients with red flags and helped them with their problems. … e-Coaching: Interactive Voice Response-Enhanced Care Transition Support for Complex Patients - 2012 … The E-Coach technology-assisted care transition system: a pragmatic randomized trial.

12. ICU-to-Ward Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions3.html
    June 01, 2023 - Transitions Next Steps and a Call to Action References Similar to the ED-to-inpatient transition … At this transition, patients with complex life-threatening problems transition from the care of a critical … Standardized ICU discharge criteria are lacking, and the transition to a lower resourced setting with … recalled at least one adverse event specifically related to communication failures in the ICU-to-ward transition … from the ICU to the ward despite it being a high-risk transition of care.

13. Children admitted to the hospital should have documentation in their hospital medical record of a transition record | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/documentation.html
    August 01, 2021 - Children admitted to the hospital should have documentation in their hospital medical record of a transition … Associated NQF # and Name:  None Measure Technical Specifications and Other Supporting Documents: Transition … Measures MR Abstraction Tool Guidelines  (DOC) Transition Measures MR List of Questions  (DOC) Transition … Measures MR Abstraction Tool  (DOC) Transition Measures MR Scoring Specifications  (DOCX) Transition

14. Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-146-fullreport.pdf
    January 01, 2020 - (1) transition policy, (2) transition tracking and monitoring, (3) transition readiness assessment, … for health care transition. … , transition preparation, and health insurance during transition. … In groups of post-transition young adults or parents/guardians of post-transition young adults, the … Center for Health Care Transition Improvement. Got Transition. Web page; 2014.

15. Improving Care Transitions of Hospitalized Patients With the Pharmacy Integrated Transitions Program | Digital Healthcare Research
    digital.ahrq.gov/2020-year-review/research-summary/improving-care-transitions-hospitalized-patients-pharmacy-integrated-transitions-program
    January 01, 2020 - Pharmacy Integrated Transitions Program Standardizing the hospital-to-skilled nursing facility transition … to skilled nursing facilities The transition of patient care from hospitals to skilled nursing facilities … She wants to improve the care coordination and communication throughout the transition process to ensure … Davidson and her University of Washington-based team to standardize the transition process by utilizing … an added resource of a pharmacy-led integrated transition team who will implement a structured warm

16. Measure: Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p012-ef.pdf
    January 01, 2015 - Measure: Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care Measure … : Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care Measure … Measure Importance ● The lack of effective transition from pediatric to adult-focused health care may … highlight the pervasiveness of poor transition preparation. … uniformly implement transition preparation.

17. Inpatient-to-Outpatient Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions5.html
    June 01, 2023 - Next Steps and a Call to Action References The hospital discharge, when patients transition … Deficits occur in both communication and information transfer at the inpatient-to-outpatient transition … in general is robust, the literature specifically focusing on diagnostic error at this transition is … AHRQ developed an evidence-based resource to improve the safety of the inpatient-to-outpatient transition … In conclusion, while the inpatient-to-outpatient transition poses challenges when it comes to diagnostic

18. The Telehealth Transition and Improving Health Systems | Digital Healthcare Research
    digital.ahrq.gov/program-overview/research-stories/telehealth-transition-and-improving-health-systems
    January 01, 2023 - The Telehealth Transition and Improving Health Systems Theme: Supporting Health Systems … Subtheme: Leveraging Telehealth to Improve Health Systems Evaluation of the rapid transition

19. Next Steps and a Call to Action | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions6.html
    June 01, 2023 - families with high potential for diagnostic error, regardless of the care contexts between which the transition … Table 1 highlights and summarizes specific strategies that can help mitigate diagnostic error at each transition … Care transitions, sources of error, and potential mitigating strategies Care Transition … has had some research focusing on improving the transition of care between contexts, the explicit goal … Moreover, interventions focused on mitigating diagnostic error at each transition have largely not scaled

20. Preventing Medication-Related Problems in Care Transitions to Skilled Nursing Facilities | Digital Healthcare Research
    digital.ahrq.gov/ahrq-funded-projects/preventing-medication-related-problems-care-transitions-skilled-nursing
    July 31, 2025 - Description Research Story Standardizing the hospital-to-skilled nursing facility transition … Improvements to the transition coordination process is crucial to reduce medication mishaps and avoid … Davidson and her University of Washington-based team to standardize the transition process by utilizing … an added resource of a pharmacy-led integrated transition team who will implement a structured warm … Davidson Measuring inequities in SNF transition processes to improve care The PIT program has the