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1. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
   pcmh.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. Supplemental Items for the CAHPS Hospital Survey: Interpreter Services | Agency for Healthcare Research and Quality
   pcmh.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."

3. Yale Center for Healthcare Innovation, Redesign, and Learning | Agency for Healthcare Research and Quality
   pcmh.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 .

4. Transitioning to the SOPS™ Hospital Survey Version 2.0: What’s Different and What To Expect, Part I: Main Report (pdf file)
   pcmh.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…

5. Introducing the CAHPS Child Hospital Survey (pdf file)
   pcmh.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150122/4_zoe_vecchio_and_sandra_schultz.pdf
   February 11, 2015 - Customer Service Zoë Vecchio Director of Service Excellence 49 Agenda 1.CHOC’s choice to transition … to Child HCAHPS 2.Our approach to physician engagement 50 CHOC’s choice to transition to Child … CAHPS Webcast Agenda CHOC’s Choice to Transition to Child HCAHPS Our Approach to Physician Engagement

6. Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms - Table 3 | PCMH Resource Center
   pcmh.ahrq.gov/page/coordinating-care-medical-neighborhood-critical-components-and-available-mechanisms-table-3
   June 01, 2011 - for hospitals with high readmission rates PCMH payment models with new care management fees Care transition … community grants HITECH meaningful use incentives for care coordination (e.g., evidence of use of transition

7. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy | Agency for Healthcare Research and Quality
   pcmh.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. Tool 9: Transitional Care Planning (doc file)
   pcmh.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

9. Toolkit to Engage High-Risk Patients In Safe Transitions Across Ambulatory Settings | Agency for Healthcare Research and Quality
   pcmh.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. A Boost for Health Services Research | Agency for Healthcare Research and Quality
    pcmh.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

11. TeamSTEPPS for Rapid Response Systems (pdf file)
    pcmh.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

12. TeamSTEPPS Rapid Response Systems Module | Agency for Healthcare Research and Quality
    pcmh.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

13. TeamSTEPPS: Rapid Response Systems (pdf file)
    pcmh.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.

14. Care Coordination | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/ncepcr/research/care-coordination/index.html
    September 01, 2022 - : Practice facilitation or practice coaching is one of the most promising strategies to support the transition

15. Better Outcomes through Research for Newborns | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/ncepcr/communities/pbrn/registry/better-outcomes-through-research-newborns.html
    May 04, 2015 - collaborative of pediatric clinicians and researchers who evaluate care in the birth setting and in the transition

16. NAC Member Biography: Mason B. Emert | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/cpi/about/organization/nac/emert.html
    March 01, 2024 - Nation's Data and Analytics Advisory Council, providing recommendations and guidance for the Nation's transition

17. Engaging Patients and Families in the Medical Home - Table 3 | PCMH Resource Center
    pcmh.ahrq.gov/page/engaging-patients-and-families-medical-home-table-3
    June 01, 2010 - Emotional support and alleviation of fear and anxiety Involvement of family and friends Continuity and transition

18. Tool: I-PASS | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
    July 01, 2023 - "watcher," unstable P atient Summary Summary Statement Events leading up to admission or care transition

19. Tools for Implementing the PCMH | PCMH Resource Center
    pcmh.ahrq.gov/page/tools-implementing-pcmh
    January 22, 2021 - Practice Facilitation Practice facilitation is one of the most promising strategies to support the transition

20. TeamSTEPPS Research/Evidence Base: Crew Resource Management Training | Agency for Healthcare Research and Quality
    pcmh.ahrq.gov/teamstepps-program/evidence-base/crew-resource.html
    June 01, 2023 - A transition of aviation crew resource management to hospital emergency departments: the MedTeams story