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1. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport-update-2021.pdf
   January 01, 2021 - These individual care transition strategies are part of a broader movement in primary care toward the … Evidence on Primary Care Transition Strategies Intervention Outcomes Primary care notifications when … A second theme is that many primary care-initiated care transition programs occurred within the context … This finding contrasts with most hospital-based care transition efforts that can be effective without … As such, primary care-based transition programs may be justified by value added either in experiential

2. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part I: Main Report (pdf file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hsops2-pt1-transition-updated.pdf
   June 01, 2022 - Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part I: Main Report Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect Part I: Main Report Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health an…

3. Supplemental Items for the CAHPS Hospital Survey: Interpreter Services | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/cahps/surveys-guidance/item-sets/literacy/suppl-interpreter-service-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."

4. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
   monahrq.ahrq.gov/patient-safety/resources/learning-lab/yale-center-long-desc.html
   June 01, 2020 - The specific aims were to: Improve patient safety at the time of transition through redesign of transfers … Mapping the care transition from hospital to skilled nursing facility. … Conversations Across the Continuum: Communication During the Transition of Care From the Hospital to … Mapping the care transition from hospital to skilled nursing facility .

5. Tool 9: Transitional Care Planning (doc file)
   monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool9_trans_care.docx
   July 28, 2016 - problem, fix a problem,” the easier it will be for your hospital staff to execute a safe, effective transition … Whole-Person Transitional Care Planning Tool Readmissions rarely result from a singular breakdown in the transition

6. TeamSTEPPS for Rapid Response Systems (pdf file)
   monahrq.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

7. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy | Agency for Healthcare Research and Quality
   monahrq.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.”

8. TeamSTEPPS: Rapid Response Systems (pdf file)
   monahrq.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.

9. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
   monahrq.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

10. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
    monahrq.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

11. A Boost for Health Services Research | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/news/blog/ahrqviews/boost-health-services-research.html
    June 01, 2022 - As we move to reduce our carbon footprint in healthcare, there will be a transition period. … AHRQ can help the Nation figure out how we make that transition in a way that is affordable, environmentally

12. Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care (pdf file)
    monahrq.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/webinars/nyp-webinar-servati-demo-project.pdf
    October 29, 2018 - so we can provide better care and service to our patients. 29 Phase 1 Intervention: Enhanced Transition … Comments Study Design Phase 1 Intervention: Enhanced Invitation Language Phase 1 Intervention: Enhanced Transition

13. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
    monahrq.ahrq.gov/patient-safety/settings/hospital/index.html
    March 01, 2024 - Optimizing Safe Transitions provides hospitals a comprehensive set of interventions to improve the care transition … to Home: A Resource Toolkit provides customizable resources to help hospitals and families safely transition

14. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning | Agency for Healthcare Research and Quality
    monahrq.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

15. The Five Principles of Effective Primary Care-Based Care Coordination for Reducing Potentially Preventable Readmissions (pdf file)
    monahrq.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

16. Information to Help Hospitals Get Started (doc file)
    monahrq.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

17. Agency for Healthcare Research and Quality
    monahrq.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

18. New Models of Primary Care Workforce - Case Example #6: Henry Ford Health System (pdf file)
    monahrq.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

19. Using Digital Health Tools to Improve Patient Safety during Acute Care | Agency for Healthcare Research and Quality
    monahrq.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,

20. Resources and Tools To Improve Discharge and Transitions of Care and Reduce Readmissions | Agency for Healthcare Research and Quality
    monahrq.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 …