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101. Measure: Pediatric All-Condition Readmission Measure (pdf file)
     ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_14-p008-1-ef.pdf
     October 01, 2014 - have demonstrated that QI interventions focused on improving the quality of the discharge process, the transition … Preventing the rebound: improving care transition in hospital discharge processes.

102. Findings | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/findings.html
     August 01, 2022 - Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event … hospital’s clinical and administrative documents to identify potential failures occurring during the transition … (tasks, organization, patient/caregiver, provider, technology and tools, and environment) and care transition … This project also found that of the 13 claims judged to have potentially involved a suboptimal care transition

103. 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

104. 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

105. 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

106. 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

107. 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

108. 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

109. 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

110. 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

111. 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

112. 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

113. 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

114. 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

115. 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

116. 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

117. 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,

118. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
     ce.effectivehealthcare.ahrq.gov/patient-safety/resources/improve-discharge/index.html
     July 01, 2022 - 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 …

119. 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 …

120. 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