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1. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
   talkingquality.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)
   talkingquality.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
   talkingquality.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
   talkingquality.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. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy | Agency for Healthcare Research and Quality
   talkingquality.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.”

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

7. Implementing the New CAHPS® Protocol for Obtaining Patient Comments About Their Care (pdf file)
   talkingquality.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

8. A Boost for Health Services Research | Agency for Healthcare Research and Quality
   talkingquality.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

9. AHRQ's Quality & Patient Safety Programs by Setting: Hospital | Agency for Healthcare Research and Quality
   talkingquality.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

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

11. Information to Help Hospitals Get Started (doc file)
    talkingquality.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

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

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

14. Information to Help Hospitals Get Started (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/About_the_Guide_508.pdf
    May 13, 2013 - Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition

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

16. Information to Help Hospitals Get Started (doc file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/About_the_Guide_508.docx
    May 13, 2013 - Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition

17. Planning Grants Final Evaluation Report: Longitudinal Evaluation of the PSML Reform Demonstration Program (pdf file)
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/candor/psml-planning-grants-final-report.pdf
    May 01, 2016 - To fill a gap in existing tools, two surveys were developed and tested to assess care transition quality … Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event … (tasks, organization, patient/caregiver, provider, technology and tools, and environment) and care transition … Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event … To examine existing tools for assessing care transition quality, the project team reviewed articles

18. Care Coordination | Agency for Healthcare Research and Quality
    talkingquality.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

19. TeamSTEPPS Research/Evidence Base: Crew Resource Management Training | Agency for Healthcare Research and Quality
    talkingquality.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

20. Identifying Strategies to Improve Medication Safety at Home | Agency for Healthcare Research and Quality
    talkingquality.ahrq.gov/funding/grantee-profiles/grtprofile-xiao.html
    November 01, 2022 - take on the responsibility for medication management, including during the high-risk period during transition