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  1. psnet.ahrq.gov/issue/learning-lawsuits-using-malpractice-claims-data-develop-care-transitions-planning-tools
    January 21, 2019 - Patients are at risk for adverse events after they transition from hospital to home.
  2. datatools.ahrq.gov/nhqdr/glossary/
    January 01, 2022 - Readmission Reference Group Same quality Small metro Social Determinants of Health (SDOH) Transition … Measures of care coordination include measures of transition of care, sharing medication information, … Transition of care  – The movement of a patient from one setting of care to another.
  3. www.ahrq.gov/patient-safety/settings/hospital/match/chapter-1.html
    July 01, 2022 - A publication in 2001 by Rozich and Resar quantified discrepancies during key transition points such … Additional studies have validated vulnerabilities during these transition points: Variances between … preventable hospital acquired conditions and to help patients heal without complication by improving the transition
  4. digital.ahrq.gov/ahrq-funded-projects/use-ehr-metadata-assess-hospital-discharge-planning-post-acute-transitions
    January 31, 2025 - Transitions in Care Transitions in care are often poorly coordinated and disruptive to those who transition
  5. www.ahrq.gov/patient-safety/reports/candor-demo-program/plan-grants/appa.html
    August 01, 2022 - Of the 230 claims examined, 13 (5.7%) were determined to involve a potential transition of care event … and incident reports from the target hospital) to identify potential failures occurring during the transition … (tasks, organization, patient/caregiver, provider, technology and tools, and environment) and care transition … project team also found that of the 13 claims judged to have potentially involved a suboptimal care transition … To examine existing tools for assessing care transition quality, the project team reviewed articles on
  6. psnet.ahrq.gov/issue/designing-and-delivering-whole-person-transitional-care-hospital-guide-reducing-medicaid
    March 27, 2019 - readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition
  7. www.ahrq.gov/news/newsroom/case-studies/cquips1002.html
    October 01, 2014 - readmission rates by providing clinicians with proven resources and expert mentoring to improve the discharge transition
  8. digital.ahrq.gov/sites/default/files/docs/publication/r18hs017817-field-final-report-2012.pdf
    January 01, 2012 - This transition is uniquely challenging because of the complex healthcare needs of this population. … This transition is uniquely challenging because of the complex healthcare needs of this population, … care is often provided in skilled nursing facilities, where it includes the skilled care needed to transition … Methods Intervention The HIT-based intervention focused on key aspects of the transition of care … develop an automated system providing information to primary care physicians when their patients transition
  9. www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions2.html
    June 01, 2023 - In conclusion, the ED-to-hospital transition is a high-risk time for diagnostic errors.
  10. www.ahrq.gov/cahps/surveys-guidance/nh/resident/Development-Resident-Surveys.html
    April 01, 2018 - Additional testing to develop composites and transition items .
  11. www.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,
  12. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/About_the_Guide_508.pdf
    April 02, 2025 - Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition
  13. www.ahrq.gov/ncepcr/research/disseminating-evidence/pcph.html
    September 01, 2024 - report synthesizes findings across five of the topics and identifies three overarching themes: a need to transition
  14. digital.ahrq.gov/ahrq-funded-projects/care-transitions-and-teamwork-pediatric-trauma-implications-health-information
    January 01, 2023 - Both prototypes, The Trauma Team Centric Information Technology (TACIT) and the Teamwork Transition Technology … Method: Qualitative , Structured/Semi-Structured Interview Population: Nurse , Physician Care transition … Care transition of trauma patients: Processes with articulation work before and after handoff.
  15. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool4_comm_inv.docx
    April 02, 2025 - ] · · Accountable care organization with care management or transition care [high-risk-care management
  16. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetrans_toolkit.pdf
    December 01, 2017 - Patients who transition from one ambulatory care facility clinician to another are especially vulnerable … Patients who transition from one clinician to another are especially vulnerable to patient-safety errors … ■ Synchronous communication ■ Interoperability ■ Information that moves with the patient during transition … .4 This model, while designed for an inpatient setting, outlines the key components of a successful transition … The proposed workflow assumed the sites could identify patients who would need transition of care support
  17. www.ahrq.gov/cahps/surveys-guidance/nh/index.html
    August 01, 2023 - difference is that the Discharged Resident Instrument also covers therapy services (and may cover the transition
  18. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/About_the_Guide_508.docx
    April 02, 2025 - Discharge Planning helps reduce preventable readmissions by engaging patients and family members in the transition
  19. www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/safetransitions/safetransitions_finalreport.docx
    November 01, 2017 - Patients who transition from one ambulatory care facility clinician to another are especially vulnerable … Patients who transition from one clinician to another are especially vulnerable to patient-safety errors … .4 This model, while designed for an inpatient setting, outlines the key components of a successful transition … care setting and during the discharge process to help prepare patients and their caregivers for the transition … The proposed workflow assumed the sites could identify patients who would need transition of care support
  20. digital.ahrq.gov/ahrq-funded-projects/improving-care-transitions-complex-patients-through-decision-support
    January 01, 2023 - When the decision support system detected a care transition, four information interventions could be