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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/PrimaryCareEffortsToReduceReadmissions-envscan.pdf
March 01, 2020 - Key Findings
• The primary care-based literature on care transition programs is less developed than … Care transition
programs in the context of more general primary care transformation efforts, such
as … Primary care may play a small to large role in care transition
interventions, and the complexity of … In both cases, a care navigator meets the patient face to face to assist in the care
transition, but … Impact of an integrated transition
management program in primary care on hospital readmissions.
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preventiveservices.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…
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preventiveservices.ahrq.gov/pcor/ahrq-pcor-trust-fund-training-projects/pcortf-tcdhs12007.html
June 01, 2018 - Trust Fund
RFA-HS-12-007 and RFA-HS-13-002
The Pathway to Independence Award facilitates the transition … The expected output of these grants is accelerated transition to tenure and productivity of PCOR researchers
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preventiveservices.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.
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preventiveservices.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.”
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preventiveservices.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
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preventiveservices.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
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/professionals/education/curriculum-tools/teamstepps/rrs/rrsinstructmod.ppt
January 01, 2008 - 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? … An example of transition support is an individual who serves on more than one team in an assembly line … ”)
SAY:
In the context of the RRS, transition support applies to the liaison roles taken on by nurses … This transition of care can include:
Transferring the patient to another unit.
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preventiveservices.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
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preventiveservices.ahrq.gov/pcor/ahrq-pcor-trust-fund-training-projects/index.html
January 01, 2024 - Independence in Patient-Centered Outcomes Research
The Pathway to Independence Award facilitates the transition … The expected output of these grants is accelerated transition to tenure and productivity of PCOR researchers
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preventiveservices.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
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preventiveservices.ahrq.gov/sites/default/files/wysiwyg/patient-safety/settings/mcc-summit/mcc-summit-bayliss.pdf
September 28, 2021 - Frequent components
► Coordination/ communication, tailored assessment and care, social
support, transition
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preventiveservices.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
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preventiveservices.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
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preventiveservices.ahrq.gov/patient-safety/resources/improve-discharge/index.html
July 01, 2022 - Skip to main content
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preventiveservices.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool1.html
March 01, 2013 - below, that the hospital undertakes during and after the hospital stay to ensure a smooth and effective transition … The result of hospitals' failure to ensure an effective transition has included adverse events, high … The goal of this theme was to measurably improve the quality of care for Medicare beneficiaries who transition
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preventiveservices.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
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preventiveservices.ahrq.gov/patient-safety/resources/learning-lab/index.html
April 01, 2024 - The project 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 . … In order for older adults to transition safely in their journey that begins in the ED, researchers proposed … Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality … system team, starting with analyzing the existing medication safety work system, spanning the entire transition
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preventiveservices.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
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preventiveservices.ahrq.gov/patient-safety/settings/ambulatory/reduce-readmissions-prim-envscan.html
March 01, 2020 - While emerging literature addresses primary care-based transition programs, a gap remains in what is