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21. A Resource Toolkit | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/settings/hospital/resource/nicu/toolkit.html
    December 01, 2013 - This toolkit includes resources for hospitals that wish to improve safety when newborns transition home … Although the transition of the fragile infant from intensive care specialist to the ambulatory care provider … During the discharge planning and transition process, a Health Coach can help prepare the family to meet … tested as the "Safe Passages" program at Texas Children’s Hospital in Houston, is to facilitate care transition

22. Table 9. Differences in ADAPT Survey Scores Based on Boston Children's Hospital Clinical Programs (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-146-section-7-table-9.pdf
    June 02, 2025 - scores based on Boston Children’s Hospital clinical programs Clinical Program N Counseling on Transition … Based on PMCA Complexity of Chronic Disease N Counseling on Counseling on AmeriHealth Caritas Transition … 6% Noncomplex Chronic Disease 394 36%* 55% 5% Counseling on Counseling on Texas Children’s Transition … based on type of non-complex chronic disease AmeriHealth Caritas Pennsylvania N Counseling on Transition … 64 31% 38% 0% Pulmonary-Respiratory 89 40% 65% 4% Texas Children’s Health Plan N Counseling on Transition

23. OR-to-ICU Transitions | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions4.html
    June 01, 2023 - OR-to-ICU Handoff-Specific Contributors to Diagnostic Errors and Uncertainty The transition … This transition is prone to technical and diagnostic error due to not only the high patient acuity and … could be directed at understanding the best way to evaluate diagnostic safety during the OR-to-ICU transition … In conclusion, the OR-to-ICU transition is inherently high risk, and the growing body of evidence on … to mitigate the impact of cognitive biases and reduce the risk of diagnostic error in the OR-to-ICU transition

24. Chapter 6. Measure Maps and Profiles (continued, 21) | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6t.html
    June 01, 2014 - Timely Transmission of Transition Record Care Coordination Measure Mapping Table   Measurement … Timely Transmission of Transition Record Purpose: To measure the percentage of patients, regardless … of age, discharged from an inpatient facility to home or any other site of care, for whom a transition … Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges … Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges

25. Final Progress Report: Older adult safety while receiving home health services after hospital discharge (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/arbaje-report.pdf
    January 01, 2024 - For construct validity, index scores were compared among cases that differ in care transition quality … A care transition is the movement of a person from one healthcare setting to another and is frequently … , and the overall quality of the care transition. … to the hospital/SHHC transition. … The geriatric floating interdisciplinary transition team.

26. Introduction | Agency for Healthcare Research and Quality
    www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions1.html
    June 01, 2023 - when the potential for cognitive errors is high. 2 Not only do patients and families experience a transition … Each transition of care has certain underlying context-specific factors contributing to diagnostic errors … For each care transition, we will examine (1) context-specific contributors, (2) handoff or transition-specific

27. Table 8. Differences in ADAPT Survey Scores Based on Race/Ethnicity (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/outcomes/chipra-146-section-7-table-8.pdf
    June 02, 2025 - Differences in ADAPT survey scores based on race/ethnicity Boston Children’s Hospital N Counseling on Transition … White 244 31% 61% 7% Other 9 36% 58% 26% AmeriHealth Caritas Pennsylvania N Counseling on Transition … 5% White 393 32% # 54% 6% Other 28 34% 59% 0% Texas Children’s Health Plan N Counseling on Transition

28. The Medical Home Index: Revised Short Form: Pediatric. Measuring the Organization and Delivery of Pediatric Primary Care for All Children, Youth, and Families (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/mhi-rsf.pdf
    June 02, 2025 - Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012 … Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012 … Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012 … Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012 … Adult providers offer an initial "welcome" visit and a review of transition goals.

29. Transitional Care Medication Safety: Stakeholders' Perspectives | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/corbett.html
    August 01, 2017 - two case studies about patients experiencing medication discrepancies following a hospital to home transition … The transition from hospital to community settings is an exceptionally risky time for patients. 4-8 … Theme 1: Barriers to medication safety during transition from hospital to home. … due to illness severity and/or functional impairment. 29 During this fragile transition, patients and … Preventing or promptly resolving medication discrepancies during the hospital to home transition are

30. Making Healthcare Safer Practices: 15. Care Transitions (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/research/findings/making-healthcare-safer/mhs3/care-transitions-1.pdf
    March 01, 2020 - • Transition Planning: Creating a plan/process that facilitates the safe transition of patients from … Transition Planning Creating a plan/ process that facilitates the safe transition of patients … The tool is a transition record that patients leave the hospital with. … CTI • The Care Transition Measure–158,9 is a 15-question care transition measure questionnaire to assess … • The Care Transition Measure–38,9 is a 3-question care transition measure questionnaire to assess

31. Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/reports/issue-briefs/diagnostic-safety-transitions-care.pdf
    June 01, 2023 - For each care transition, we will examine (1) context-specific contributors, (2) handoff or transition-specific … In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors. … At this transition, patients with complex life-threatening problems transition from the care of a critical … from the ICU to the ward despite it being a high-risk transition of care. … Ascertaining design requirements for postoperative care transition interventions.

32. Design Guide for Implementing Warm Handoffs (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warmhandoff-designguide.pdf
    June 02, 2025 - Identify all patient transition points within the practice ...................................2 Step … In each transition, opportunities arise for breakdowns in communication that may lead to medical errors … Identify all patient transition points within the practice. … For each transition identified in Step 1, determine: � Who the sender is. � Who the receiver is. … Example Table To Document Patient Transition Points Person Giving Information?

33. Transitions of Care | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/nhqrdr/chartbooks/carecoordination/measure1.html
    June 01, 2018 - Records References The Centers for Medicare & Medicaid Services (CMS) defines a transition … A common transition of care is hospital discharge. … A successful transition depends on whether hospitals have adequately educated patients about key elements … quality care, prevent complications, teach patients at discharge, and ensure that patients make a smooth transition … quality care, prevent complications, teach patients at discharge, and ensure that patients make a smooth transition

34. Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/resources/learning-lab/re-engineering-postnatal-unit-care-long-desc.html
    April 01, 2025 - Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality … procedures for maternal-infant dyadic evaluation and management during the postnatal unit stay and discharge transition … integrated into  the Alliance for Innovation on Maternal Health (AIM) Postpartum Hospital Discharge Transition … Final Report: Re-Engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity … Progress Report: Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity

35. Final Progress Report: Medication List Consistency When Patients Transition from Hospital to Community (pdf file)
    www.ahrq.gov/sites/default/files/2024-01/kennelty-report.pdf
    January 01, 2024 - Final Progress Report: Medication List Consistency When Patients Transition from Hospital to Community … TITLE PAGE Medication List Consistency When Patients Transition from Hospital to Community Principal … This study fits into the hospital’s transition-of-care initiatives, because medication discrepancies … Mary Naylor et al. and the Care Transition by Dr. … focuses on using a care manager or nurse to aid in a seamless transition.

36. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/rev-finalreport.pdf
    March 01, 2020 - 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

37. Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care: Final Report (pdf file)
    www.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

38. Introducing the CAHPS Child Hospital Survey (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150122/4_zoe_vecchio_and_sandra_schultz.pdf
    June 02, 2025 - 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

39. Final Progress Report: Engineering Safe Care Journeys for Vulnerable Older Adults (pdf file)
    www.ahrq.gov/sites/default/files/2025-03/smith-werner-carayon-report.pdf
    January 01, 2025 - ’s home to the ED or that occur at home prior to the ED transition; 2) tasks that occur during the transition … happen before the ED to home transition at the home or in the community, during the ED to home transition … ED to hospital transition at the hospital, during the ED to hospital transition, or after the ED to … hospital transition; and 7) tasks that happen before the ED to observation unit transition at the observation … unit, during the observation unit to hospital transition, or after the ED to observation unit transition

40. Final Progress Report: Inpatient-Outpatient Transitions: Reducing the Rate of Readmissions (pdf file)
    www.ahrq.gov/sites/default/files/2025-02/jones-selna-report.pdf
    January 01, 2025 - project was to use Failure Mode Effects Analysis (FMEA) to identify modifiable risks associated with transition … These four factors are: 1) awareness of the receiving (i.e., ambulatory) party that a transition is … We first developed an idealized operational model of an inpatient-to-ambulatory care transition and, … care processes Aim 1: Develop idealized care transition model Literature review to identify … Lost in Transition: Challenges and Opportunities for Improving the Quality of Transitional Care.