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101. A Toolkit to Engage High-Risk Patients in Safe Transitions: Final Report (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetransitions_finalreport.docx
     November 01, 2017 - Patients who transition from one ambulatory care facility clinician to another are especially vulnerable … Patients who transition from one clinician to another are especially vulnerable to patient-safety errors … .4 This model, while designed for an inpatient setting, outlines the key components of a successful transition … care setting and during the discharge process to help prepare patients and their caregivers for the transition … The proposed workflow assumed the sites could identify patients who would need transition of care support

102. Chapter 6. Measure Maps and Profiles (continued, 5) | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/ncepcr/care/coordination/atlas/chapter6d.html
     June 01, 2014 - Translation and validation of the Care Transition Measure into Hebrew and Arabic. … Translation and validation of the Care Transition Measure into Hebrew and Arabic.

103. Coaching in the Hospital | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/es/patient-safety/settings/hospital/resource/nicu/coaching.html
     December 01, 2013 - provide families with the tools and support they need to promote knowledge and management of their baby's transition … The primary goal of a NICU discharge education program is to have a safe transition from the NICU to … will need equipment to create a PHR, family information, and bedside reminders to support the care transition

104. TeamSTEPPS Model for Change (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/instructor/reference/modelchange.pdf
     March 01, 2006 - TeamSTEPPS Model for Change Rooted in decades of aviation research, the transition of formal

105. The Five Principles of Effective Primary Care-Based Care Coordination for Reducing Potentially Preventable Readmissions (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-reportaddendum.pdf
     March 01, 2021 - The focus should be on facilitating a smooth transition of patients and their care plans back to the … care practices can benefit from specifying and implementing an effective posthospitalization care transition

106. A Conceptual Framework for Studying the Safety of Transitions in Emergency Care (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Behara.pdf
     January 01, 2004 - The transition of care did not simply involve the sharing of information, but also included expectations … whose assessment has started, but whose problem cannot be adequately characterized at the time of the transition

107. Information to Help Hospitals Get Started (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Ways_To_Learn_More_508.docx
     May 21, 2013 - Advancing Patient Safety organization, provides patients and families the tools that will help smooth their transition … patients with complex care needs and their family caregivers receive specific tools and work with a Transition … CoachTM to learn self-management skills that will ensure that patient needs are met during the transition

108. Tool 4: Community Inventory (doc file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool4_comm_inv.docx
     September 02, 2016 - ] · · Accountable care organization with care management or transition care [high-risk-care management

109. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html
     December 01, 2017 - Engaging patients and families in the discharge planning process helps make this transition in care safe

110. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/tools/index.html?page=4
     June 01, 2023 - This toolkit provides customizable resources for hospitals that wish to improve safety when newborns transition

111. Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/es/tools/index.html?page=4
     June 01, 2023 - This toolkit provides customizable resources for hospitals that wish to improve safety when newborns transition

112. PQMP Measures | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/pqmp/measures/index.html?page=6
     April 24, 2024 - Health COE: Children's Hospital of Philadelphia (CHOP) Adolescent Assessment of Preparation for Transition

113. Appendix A. Grantee Profiles | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
     August 01, 2022 - Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event … and incident reports from the target hospital) to identify potential failures occurring during the transition … (tasks, organization, patient/caregiver, provider, technology and tools, and environment) and care transition … project team also found that of the 13 claims judged to have potentially involved a suboptimal care transition … To examine existing tools for assessing care transition quality, the project team reviewed articles on

114. PQMP Measures | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/pqmp/measures/index.html?page=3
     April 24, 2024 - Children admitted to the hospital should have documentation in their hospital medical record of a transition

115. Chapter 3. Developing Change: Designing the Medication Reconciliation Process | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/match/chapter-3.html
     July 01, 2022 - efficiencies through streamlined process steps and integration into existing workflow with consideration to transition … understanding the needs of various departments and clinical roles and responsibilities of staff at each transition … Below are various transition points that should be considered as you build a plan to improve the medication … nuances within various practice settings create challenges for medication reconciliation when patients transition

116. New Models of Primary Care Workforce - Case Example #6: Henry Ford Health System (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_6.pdf
     October 01, 2016 - Academic activities include the Continuity, A-PCTC (K15), and Transition of care clinics, and research … A team of resident physicians and MAs manages the care transition, usually in a single visit, and hands … MAs call patients after discharge following a protocol for transition care management. … Care and transition management of high- risk patients Care management is by RN case managers. … An MA and backup MA are dedicated to following up and scheduling patients for care-transition visits

117. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions.html
     June 01, 2023 - Skip to main content An official website of the Department of Health and Human Services Careers Contact Us Español FAQs Search all AHRQ sites Search small Search Menu …

118. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/funding/grantee-profiles/grtprofile-dalal.html
     January 01, 2024 - Care transition or moving from one healthcare setting to another, such as from the hospital to home,

119. Excelling on CAHPS: Lessons from Top-Performing Medicaid and CHIP Health Plans (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150317/christopher_sellers.pdf
     January 01, 2014 - between 100-146% FPL • CHIP-funded • AL Medicaid administered Medicaid/CHIP Churning • As relates to transition

120. Information to Help Hospitals Get Started (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/About_the_Guide_508.pdf
     May 13, 2013 - Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition