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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. 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

8. 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

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. 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

11. 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

12. 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

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. 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 …

15. 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

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. 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

20. Slide 1
    talkingquality.ahrq.gov/sites/default/files/wysiwyg/news/events/conference/2011/naylor/naylor.pptx
    January 01, 2011 - Slide 1 AHRQ 2011 Annual Conference Leading Through Innovation & Collaboration September 19, 2011 The Transitional Care Model Mary D. Naylor, PhD, RN, FAAN Marian S. Ware Professor in Gerontology Director, NewCourtland Center for Transitions and Health University of Pennsylvania School of Nursing Translating Resear…