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41. Overview | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/overview.html
    July 01, 2021 - An effective transition will support the likelihood of reducing the incidence of inappropriate care and … provided a starting place for identifying best practices for improving performance on the hospital-to-home transition

42. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/rrs/instructor_slides/rrsinstructmod.html
    October 01, 2014 - Support ("Boundary Spanning") Transition Support ("Boundary Spanning") (continued) Example of One … How did the response team know when and where to transition the patient to another care unit? … Did the Responders understand the role of the nursing staff in easing transition? … Return to Top Transition Support ("Boundary Spanning") Say: Transition support, or "boundary … This transition of care can include: Transferring the patient to another unit.

43. Section 7.B, Tables 13 and 14 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-13-14.pdf
    March 09, 2018 - -14 33.3 28.6 Protocols/Plans Child has shared care plan FECC-16 40.0 48.8* Child has written transition … child’s condition Protocols/Plans Child has shared care plan FECC-16 40.9 49.1 Child has written transition

44. TeamSTEPPS for Rapid Response Systems (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrs_slides/rrsslides.pdf
    January 01, 2008 - Inter-Team Knowledge Supports effective transitions in care between units Is a prerequisite for transition … requires… Administration requires… Patient needs… TEAMSTEPPS 05.2Mod 1 05.2 Page 20Page 20 RRS Transition … support Example: Activator becoming Responder TEAMSTEPPS 05.2Mod 1 05.2 Page 21Page 21 RRS Transition … team, stroke team, etc) A revised plan of care TEAMSTEPPS 05.2Mod 1 05.2 Page 40Page 40 RRS RRS Transition … Support�(“Boundary Spanning”) Transition Support�(“Boundary Spanning”) Example of One RRS Example

45. Module-8-Slides (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-8-slides.pdf
    November 18, 2021 - Clinician-to-clinician hand-off to inpatient/rehab CR Programs  Phase II collaboration Phase I transition … to Phase II PARTICIPANTS 30 Phase I GOAL: Strive for a smooth, timely transition Phase II Develop … education visit – Inpatient CR  Time from Referral to Enrollment and/or attendance at first session --Transition …  Percentage of referrals who enroll -- Transition  Percent of patients attending CR orientation

46. Section 7.A, Tables 11 and 12 (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-11-12.pdf
    March 09, 2018 - Protocols/Plans Child has shared care plan FECC-16 36.4 52.4*** 65.9*** 41.2 Child has written transition … Protocols/Plans Child has shared care plan FECC-16 37.5 53.7*** 62.6*** 40.8 Child has written transition

47. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-healthlit-items.html
    October 01, 2023 - Add a transition statement to indicate a transition from the HCAHPS questions. … To find CMS’s mandatory transition statement, please refer to the HCAHPS Quality Assurance Guidelines … on HCAHPS and search for “mandatory transition statement.”

48. Guide for Safe Transitions to New Appointments (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_guide.pdf
    December 01, 2017 - Patients who transition from one clinician to another (e.g., primary care clinician to specialist clinician … medical and non-medical conditions that can affect the patient’s plan of care, especially during a transition … Primary Care Guide for Transition Interventions. https://www.jointcommission.org/assets/1/6/TOC_ Hot_Topics.pdf

49. Design Guide for Warm Handoff Plus (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
    April 03, 2018 - In each transition, opportunities arise for breakdowns in communication that may lead to medical errors … A Warm Handoff Plus is a transition conducted in person between two members of the healthcare team in … Identify patient transition points within the practice. … For each transition identified in Step 1, determine: � Who is handing off the patient or information

50. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
    April 18, 2004 - Baker, Brad Bjornstad, Jay Wolfson Abstract Background: “Seamless care” is a smooth and safe transition … Continuity of care is most critical during the patient’s transition from the institutional acute care … Many studies have examined the transition of patients from the hospital to the home, and have focused … Communication issues Understanding the patient’s care transition story is important to our ability … to design practical and effective interventions for smoothing the transition from the hospital to the

51. TeamSTEPPS: Rapid Response Systems (pdf file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/instructor_slides/rrsinstructmod.pdf
    January 01, 2008 - How did the response team know when and where to transition the patient to another care unit? … Did the Responders know the role of the ICU team when making the decision to transition the patient … Did the Responders understand the role of the nursing staff in easing transition? … Transition support can also enhance the safety and effectiveness of patient transfers by ensuring … This transition of care can include: •Transferring the patient to another unit.

52. About the Measure | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/pqmp/implementation-qi/toolkit/h2h/about.html
    July 01, 2021 - and content of discharge instructions to families/caregivers are essential for ensuring a successful transition … The measures for this toolkit were developed to capture the quality of care coordination in transition

53. Chapter 6. Measure Maps and Profiles (continued, 20) | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/ncepcr/care/coordination/atlas/chapter6s.html
    June 01, 2014 - report. 1 This measure is intended for use in conjunction with two other PCPI measures (Measure #58, Transition … Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges) Care … Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges) Purpose … from an inpatient facility to home or any other site of care, or their caregiver(s), who received a transition … Reconciled Medication List Received by Discharged Patients; and Measure #59, Timely Transmission of Transition

54. THE MEDICAL HOME INDEX: (doc file)
    ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/mhi-rsf.docx
    March 25, 2009 - Pediatric and adolescent PCPs support youth & family to manage their health using a transition time line … Adult providers offer an initial "welcome" visit and a review of transition goals. … In addition to level 3, progressively from age 12, youth, family and PCP develop a written transition … Youth and families receive coordination support to link their health and transition plans with other … Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012

55. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/teamstepps/rrs/rrs_slides/rrsslides.html
    July 01, 2018 - Teamwork & RRS Necessary Teamwork Skills Inter-Team Knowledge Inter-Team Knowledge (continued) Transition … Support ("Boundary Spanning") Transition Support ("Boundary Spanning") (continued) Example of One … Assessment & Stabilization CUS Words Patient Disposition Patient Disposition (continued) RRS Transition … Inter-Team Knowledge Supports effective transitions in care between units Is a prerequisite for transition … Return to Top Transition Support ("Boundary Spanning") Requires inter-team knowledge Combines

56. The Medical Home Index: Revised Short Form: Pediatric | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/policymakers/chipra/demoeval/what-we-learned/mhi-rsf.html
    May 01, 2013 - COMPLETE __ PARTIAL __ COMPLETE __ PARTIAL __ COMPLETE __ PARTIAL __ COMPLETE 7 #2.5 Supporting the Transition … Pediatric and adolescent PCPs support youth & family to manage their health using a transition time … Adult providers offer an initial "welcome" visit and a review of transition goals. … In addition to level 3, progressively from age 12, youth, family and PCP develop a written transition … Youth and families receive coordination support to link their health and transition plans with other

57. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/hai/tools/ambulatory-care/safe-transitions.html
    December 01, 2017 - Patients who transition from one ambulatory care facility clinician to another are especially vulnerable

58. Tool 3: How To Deliver the Re-Engineered Discharge at Your Hospital | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool3.html
    March 01, 2013 - Discussion with family members and other caregivers is also important to a successful transition. … Caregivers' understanding of the discharge plan will be critical to a safe transition home. … caregivers understand your role as the DE and how you will help the patient make a safe and smooth transition … The DE will help you learn the essential new information you will need to make a safe transition from … Encourage patients to identify someone who can support them during their transition to include in the

59. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - costs associated with preventable ADEs occurring in both inpatient and outpatient settings. 8,9 The transition … patients may result in ADEs. 29 Such human factors resulting in ADEs are particularly common during transition … that can help identify patients who may be at risk for experiencing medication-related ADEs during transition … Conclusion Medication discrepancies frequently occur during the transition from hospital to home care … The hospital discharge: a review of high risk care transition with highlights of a reengineered discharge

60. AHRQ's Digital Solutions to Support Care Transitions Challenge | Agency for Healthcare Research and Quality
    ce.effectivehealthcare.ahrq.gov/challenges/past/care-transitions/index.html
    January 01, 2022 - hospital, primary care, and community partner care teams throughout the hospital discharge to home transition … Hospital Discharge   Colorado UTHealth MyInfantCare—A Digilego App to Assist Parents in a Successful Transition