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  1. digital.ahrq.gov/sites/default/files/docs/citation/r01hs024537-sockolow-final-report-2020.pdf
    January 01, 2020 - Problems exist with information transfer during the transition to HHC(5, 8, 10- 15) and HHC clinicians … The Joint Commission defines accurate communication of medication information across the transition … Getting to complete and accurate medication lists during the transition to home health care. … Hospital to nursing home transition challenges: perceptions of nursing home staff. … Transition to home care: Quality of mental health, pharmacy, and medical history information.
  2. digital.ahrq.gov/sites/default/files/docs/coordination-patients-complex-needs-slides-022014.pdf
    February 20, 2014 - Discharge Process: Response Always or Usually (n = 150) Baseline Intervention p-value The care transition … February 20, 2014 28 Background • Managing medications during the transition to home health … Summary: to patient’s medical home o Letter: to patient o Release of information request: to care transition … • Sites already receiving patient care transition information requested interventions turned off. … necessary; 69% were completed. 65 Discussion • Conclusions ► Demonstrated CDS facilitated care transition
  3. www.ahrq.gov/ncepcr/reports/grants-transform/references.html
    March 01, 2017 - Multi-Method Evaluation of Physician Group Incentive Programs for Patient-Centered Medical Home Transition … Becoming a patient-centered medical home: a 9-year transition for a network of Federally Qualified Health
  4. www.ahrq.gov/patient-safety/resources/learning-lab/index.html
    April 01, 2025 - The project 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 . … Improve transition of care outcomes after the ED encounter was complete by reducing: (a) unnecessary … Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality … Re-engineering Postnatal Unit Care and the Transition Home to Reduce Perinatal Morbidity and Mortality
  5. psnet.ahrq.gov/primer/patient-safety-indicators
    June 15, 2024 - PSIs have since been updated and refined annually to stay current with coding updates (such as the transition … This transition has prompted a body of research on evaluating, measuring, and preventing patient safety … In 2022, CMS published the Digital Quality Measures Strategic Roadmap , which outlines its transition
  6. psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
    February 06, 2019 - July 5, 2023 Care transition of trauma patients: processes with articulation work before
  7. psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
    September 01, 2011 - orders to all of the medications that the patient has been taking.( 2 ) This should be done at every transition … Safety Goal, focusing nationwide attention on the issue of inpatient medication errors as patients transition … called to the floor was not appropriately acted upon, perhaps secondary to nursing inexperience, a transition
  8. hcup-us.ahrq.gov/tech_assist/toolstutorial/508/508course.jsp
    January 01, 2020 - provide information about the International Classification of Diseases (ICD) coding system, including the transition … The transition replaced the ICD-9-CM diagnosis and procedure coding system with the ICD-10-CM diagnosis … The number of both diagnosis and procedure codes increased with the transition to ICD-10-CM/PCS. … Key Difference 2: Diagnostic information is removed from procedure codes With the transition … In addition, the tutorial provided a high-level overview of how the transition from ICD-9-CM to ICD-10
  9. psnet.ahrq.gov/issue/effectiveness-pharmacist-intervention-reduce-medication-errors-and-health-care-resources
    August 04, 2021 - Medication-related interventions to improve medication safety and patient outcomes on transition
  10. digital.ahrq.gov/location/usa-oh-columbus
    January 01, 2023 - A Randomized Clinical Trial of Smartphone Virtual Reality for Pain Management During Burn Care Transition
  11. www.ahrq.gov/sites/default/files/wysiwyg/cahps/news-and-events/events/20150317/christopher_sellers.pdf
    January 01, 2014 - between 100-146% FPL • CHIP-funded • AL Medicaid administered Medicaid/CHIP Churning • As relates to transition
  12. 0129Table8 (pdf file)

    www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/fullreports/0129table8.pdf
    January 01, 2013 - Evidence Key Findings Citation Readmission and Quality of Care Coordination, Discharge, and Care Transition … Preventing the rebound: improving care transition in hospital discharge processes. … Intense self-management and transition coaching of patients at high risk of readmission, and the use … patients at the time of hospitalization and randomized them to receive routine care or a care transition … to take a more active role in self-care; and 3) continuity across settings and guidance from a transition
  13. psnet.ahrq.gov/issue/toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety
    August 01, 2012 - The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition
  14. psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
    February 26, 2025 - complex surgical patients to follow up with the provider who saw them in the hospital to improve the transition … benefit from dedicating resources to develop a robust post-discharge follow-up program that supports the transition … post-discharge follow-up programs require bundled care changes that span the inpatient and outpatient transition
  15. datatools.ahrq.gov/nhqdr/
    January 01, 2023 - Measures of care coordination include measures of transition of care, sharing medication information, … Measures of care coordination include measures of transition of care, sharing medication information, … Measures of care coordination include measures of transition of care, sharing medication information, … It also looks at short-term post-acute care to safely transition people from the hospital to independent
  16. www.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
    June 01, 2023 - watcher," unstable Patient Summary Summary statement Events leading up to admission or care transition
  17. www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Ways_To_Learn_More_508.pdf
    October 28, 2009 - 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
  18. www.ahrq.gov/ncepcr/care/coordination/atlas/chapter5.html
    June 01, 2014 - The program aims to achieve this by actively facilitating the transition from the inpatient to outpatient … setting, using a patient-centered case management approach to facilitate care during this transition … Intervention mechanism: Facilitate transition from inpatient to outpatient setting → Domain: Facilitate
  19. www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-care-coordination.pdf
    June 01, 2024 - 2008 $191,840 Purpose: To improve the quality, safety, and continuity of patient care during the transition … Patients who transition from one ambulatory care facility clinician to another are especially vulnerable … The Index of Home Health Care Transition Quality, a 12-item count of safe transition practices available … Wisconsin - Madison Madison, Wisconsin R36 HS21984 [Grant] Medication List Consistency When Patients Transition … Techniques for Transitions of Care in Integrated Delivery Systems 2002-2003 $99,916 Purpose: To examine transition
  20. psnet.ahrq.gov/issue/disparate-perspectives-exploring-healthcare-professionals-misaligned-mental-models-older
    May 11, 2022 - May 11, 2022 Care transition of trauma patients: processes with articulation work before