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digital.ahrq.gov/ahrq-funded-projects/using-health-information-technology-improve-health-care-quality-primary-care-va/publication/handbook
January 01, 2023 - Using Health Information Technology to Improve Health Care Quality in Primary Care Practices and in Transitions
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digital.ahrq.gov/sites/default/files/docs/page/2006ClancyKeyesYoung_051211comp.pdf
June 16, 2021 - Transitions represent vulnerable points in care and we are still
learning how to manage them. … Managing the critical points in transitions.
What Did We Learn? … Care transitions must be improved. … A web-based CCR and e-transitions system allows
communication between MDs and home care nurses.
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digital.ahrq.gov/location/usa-me-presque-isle
January 01, 2023 - Eastern, and Central Maine by planning for the standard exchange of clinical information for patient transitions
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digital.ahrq.gov/medical-condition/trauma
January 01, 2024 - Principal Investigator
Gurses, Ayse Pinar
Project Name
Care Transitions and Teamwork … Principal Investigator
Gurses, Ayse Pinar
Project Name
Care Transitions and Teamwork
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digital.ahrq.gov/ahrq-funded-projects/human-factors-home-health-care/annual-summary/2011
January 01, 2011 - Due to unexpected transitions in project leadership in 2010, the project was slightly delayed and therefore … evidence and evidence-based tools to support patient- centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/use-hit-increase-primary-care-access-medicaid-patients/annual-summary/2012
January 01, 2012 - program to improve access to primary care for Medicaid patients and improve coordination of care across transitions … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/improving-pediatric-cancer-survivorship-care-through-survivorlink
January 01, 2023 - Children
Type of Care
Pediatrics
Health Care Theme
Patient Education
Transitions … Facilitate the exchange of clinical information at key transitions.
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digital.ahrq.gov/ahrq-funded-projects/automatic-notification-system-test-results-finalized-after-discharge/annual-summary/2012
January 01, 2012 - and acknowledgement of test results by responsible inpatient and ambulatory physicians during care transitions … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/using-location-based-smartphone-alerts-within-system-care-coordination
January 01, 2023 - Populations
Type of Care
Acute Care
Health Care Theme
Care Coordination
Transitions … Role of Health IT to Improve Care Transitions AHRQ hosted a free Webinar to discuss how health IT can … improve care transitions for patients with complex conditions
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017029-kaushal-final-report-2011.pdf
January 01, 2011 - care settings, such as the inpatient to the outpatient setting.4
Use of HIT and HIE to improve care transitions … A particularly
vulnerable time for patients, in terms of risk for ADEs, are transitions across care … Recognizing the challenges
associated with transitions and refining CDS within systems may help maximize … Care transitions: a threat and an
opportunity for patient safety. Am J Med Qual. … Risk Factors for Unexplained Medication
Discrepancies During Transitions in Care (To be submitted
to
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2011
January 01, 2011 - cause injury or even fatalities and happens in all types of health care settings, including patient transitions
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digital.ahrq.gov/ahrq-funded-projects/data-flow-clinical-outcomes-perinatal-continuum-care-system/annual-summary/2012
January 01, 2012 - Amount
$335,705
Summary: Medical errors are often caused by poor communication, especially during transitions … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/longitudinal-telephone-and-multiple-disease-management-system-improve/annual-summary/2011
January 01, 2011 - diseases and socio-demographic vulnerabilities who experience increased health care utilization and transitions … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/human-factors-home-health-care/activity/human-factors-home-health-care/annual-summary/2010
January 01, 2010 - Because of the unexpected transitions in project leadership, the project was slightly delayed and has … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/e-coaching-interactive-voice-response-ivr-enhanced-care-transition-support/annual-summary/2011
January 01, 2011 - evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/sites/default/files/docs/2010-04-06%20Patient%20Empowerment%20(1).pdf
January 01, 2010 - Video or telephone‐based counseling
• Internet or IVR‐supported Stepped‐Care
Approach
The Care Transitions … survey 7 (and 2 yellow flags)
Conclusions
• Patient engagement is a critical element of
safe care transitions … the Problem: UAB Hospital
Challenge of Current Care Transition Models
Possible Solutions
The Care Transitions
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digital.ahrq.gov/sites/default/files/docs/coordination-patients-complex-needs-slides-022014.pdf
February 20, 2014 - Have no financial, personal, or professional conflicts of interest to disclose.
2
Improving Care Transitions … Transfer System
to Outpatient Providers
5
Project Objectives
• To achieve, especially at care transitions … Feldman, P.I.
50
Improving Care Transitions for
Complex Patients Through Decision
Support
Eric … R18 HS017795
52
Goal and Objectives
• To determine whether CDS messaging can
facilitate care transitions … Delivery, and Practice
Lessons Learned
Acknowledgments
Acknowledgments (continued)
Improving Care Transitions
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digital.ahrq.gov/ahrq-funded-projects/medication-reconciliation-improve-quality-transitional-care/annual-summary/2012
January 01, 2012 - cause injury or even fatalities and happens in all types of health care settings, including patient transitions
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digital.ahrq.gov/ahrq-funded-projects/modeling-and-analysis-clinical-care-health-information-technology-improvement/annual-summary/2012
January 01, 2012 - Apply re-refined techniques to a third study site, the area of hospital admissions, with intensive care transitions … evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions
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digital.ahrq.gov/ahrq-funded-projects/use-hit-increase-primary-care-access-medicaid-patients
January 01, 2023 - Medicaid
Type of Care
Primary Care
Health Care Theme
Care Coordination
Transitions … was to improve access to primary care for Medicaid patients and improve coordination of care across transitions