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61. High-Hanging Fruit: Improving Transitions in Health Care (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Perry_49.pdf
    March 27, 2008 - in most health care settings, new paperwork or software would have to be created for this type of transition … variation on readbacks, the “teachback,” has been considered as a tool for including patients in the transition … Because of pragmatic challenges involved in timing a transition update to include patients, particularly … have been noted: (1) pre-turnover, during which the individuals involved begin to prepare for transition … ; (2) arrival, where incoming and off-going workers gather; (3) meeting, during which the transition

62. Design Guide for Warm Handoff Plus (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/warm-handoff-design-guide-final508.pdf
    June 02, 2025 - In each transition, opportunities arise for breakdowns in communication that may lead to medical errors … A Warm Handoff Plus is a transition conducted in person between two members of the healthcare team in … Identify patient transition points within the practice. … For each transition identified in Step 1, determine: � Who is handing off the patient or information

63. Environmental Scan of Primary Care-Based Efforts To Reduce Readmissions | Agency for Healthcare Research and Quality
    www.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

64. Section 7.A, Tables 11 and 12 (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-166-fecc-tables-11-12.pdf
    June 02, 2025 - Protocols/Plans Child has shared care plan FECC-16 36.4 52.4*** 65.9*** 41.2 Child has written transition … Protocols/Plans Child has shared care plan FECC-16 37.5 53.7*** 62.6*** 40.8 Child has written transition

65. Supplemental Items for the CAHPS Hospital Adult Survey: Health Literacy | Agency for Healthcare Research and Quality
    www.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.”

66. Caregivers of children discharged from the hospital | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/caregivers-children-discharged.html
    August 01, 2021 - Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF, 108 KB) Transition

67. Caregivers of children discharged from the hospital who report receiving written discharge instructions | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/written-discharge-instructions.html
    August 01, 2021 - PDF) Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF) Transition

68. Medication Discrepancies and Potential Adverse Drug Events During Transfer of Care from Hospital to Home | Agency for Healthcare Research and Quality
    www.ahrq.gov/patient-safety/reports/liability/neumiller.html
    August 01, 2017 - costs associated with preventable ADEs occurring in both inpatient and outpatient settings. 8,9 The transition … patients may result in ADEs. 29 Such human factors resulting in ADEs are particularly common during transition … analysis was to evaluate the potential for medication discrepancies to contribute to ADEs during care transition … Conclusion Medication discrepancies frequently occur during the transition from hospital to home care … The hospital discharge: a review of high risk care transition with highlights of a reengineered discharge

69. Exhibit 11. Supporting Increases in Patient Knowledge, Skills, and Abilities | Agency for Healthcare Research and Quality
    www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyex11.html
    July 01, 2018 - Description Who is involved Outcomes measured Engaging and supporting patients and families in transition

70. THE MEDICAL HOME INDEX: (doc file)
    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/demoeval/what-we-learned/mhi-rsf.docx
    June 02, 2025 - Pediatric and adolescent PCPs support youth & family to manage their health using a transition time line … Adult providers offer an initial "welcome" visit and a review of transition goals. … In addition to level 3, progressively from age 12, youth, family and PCP develop a written transition … Youth and families receive coordination support to link their health and transition plans with other … Transition to adulthood indicator #2.5 revised 2006; Medical Home Index revised to create MHI-RSF 2012

71. Final Progress Report: Patient-Centric Risk Model for Medication Safety During Care Transitions (pdf file)
    www.ahrq.gov/sites/default/files/2024-02/gurses-report.pdf
    January 01, 2024 - Scope: The transition to home following hospital discharge is a high-risk period, with older adults being … Our recommendations were built on the fact that medication safety during care transition and, more so … Discharge-related tasks: during hospital to home transition-peri-discharge period and first few days … The number of tasks to be performed by patients during immediate transition was high. … Patient medication management tasks during care transition.

72. Chapter 6. Measure Maps and Profiles (continued, 20) | Agency for Healthcare Research and Quality
    www.ahrq.gov/ncepcr/care/coordination/atlas/chapter6s.html
    June 01, 2014 - report. 1 This measure is intended for use in conjunction with two other PCPI measures (Measure #58, Transition … Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges) Care … Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges) Purpose … from an inpatient facility to home or any other site of care, or their caregiver(s), who received a transition … Reconciled Medication List Received by Discharged Patients; and Measure #59, Timely Transmission of Transition

73. Caregivers of children discharged from the hospital should report that prior to discharge, they received a copy of or access to discharge instructions | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/access-discharge-instructions.html
    August 01, 2021 - PDF) Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF) Transition

74. Caregivers of children discharged from the hospital should report being offered assistance in scheduling within 72 hours of discharge from the hospital | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/offered-assistance-scheduling.html
    August 01, 2021 - PDF) Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF) Transition

75. Caregivers of children discharged from the hospital whose preferred language is other than English should report that they received discharge education in their preferred language | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/preferred-language.html
    August 01, 2021 - PDF) Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF) Transition

76. Caregivers of children discharged from the hospital should report that, prior to their child’s most recent discharge, they had an opportunity to ask questions | Agency for Healthcare Research and Quality
    www.ahrq.gov/pqmp/measures/opportunity-ask-questions.html
    August 01, 2021 - PDF) Quality of Pediatric Emergency Department-to-Home Transitions Survey Spanish Version  (PDF) Transition

77. Module 15—Infection Prevention and Antibiotic Stewardship Considerations During Care Transitions—Nursing Home Infection Preventionist Training Course | Agency for Healthcare Research and Quality
    www.ahrq.gov/nursing-home/resources/module-15-infection-prevention.html
    April 01, 2022 - importance of communication during care transitions; 2. define the characteristics of an ideal care transition

78. AHRQ Announces Interest in Funding Research on Diagnosis and Treatment of Menopause | Agency for Healthcare Research and Quality
    www.ahrq.gov/news/noi-menopause-symptoms.html
    December 01, 2024 - scaling person-centered models of care to optimize women’s health during midlife and the menopausal transition

79. Seamless Care: Safe Patient Transitions from Hospital to Home (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Spehar.pdf
    April 18, 2004 - Baker, Brad Bjornstad, Jay Wolfson Abstract Background: “Seamless care” is a smooth and safe transition … Continuity of care is most critical during the patient’s transition from the institutional acute care … Many studies have examined the transition of patients from the hospital to the home, and have focused … Communication issues Understanding the patient’s care transition story is important to our ability … to design practical and effective interventions for smoothing the transition from the hospital to the

80. Module-8-Slides (pdf file)
    www.ahrq.gov/sites/default/files/wysiwyg/takeheart/training/module-8-slides.pdf
    November 18, 2021 - Clinician-to-clinician hand-off to inpatient/rehab CR Programs  Phase II collaboration Phase I transition … to Phase II PARTICIPANTS 30 Phase I GOAL: Strive for a smooth, timely transition Phase II Develop … education visit – Inpatient CR  Time from Referral to Enrollment and/or attendance at first session --Transition …  Percentage of referrals who enroll -- Transition  Percent of patients attending CR orientation