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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/medicaidreadmitguide/mcaidread_tool9_trans_care.docx
July 28, 2016 - Tool 9: Transitional Care Planning
Tool 9: Whole-Person Transitional Care Planning Tool
Purpose
The social, economic, and geographic conditions in which individuals live have a profound impact on individuals’ health status. Efforts to reduce readmissions by optimizing self-management or long-term health status will …
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pbrn.ahrq.gov/patient-safety/settings/hospital/index.html
March 01, 2024 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit features strategies from the field … set of medication reconciliation tools to reduce medication errors that frequently occur during care transitions … Project BOOST (Better Outcomes by Optimizing Safe Transitions provides hospitals a comprehensive set
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pbrn.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy3/index.html
December 01, 2017 - Patients and families can play a role to make sure these transitions in care are safe and effective. … Patients and Families as Advisors
Strategy 2: Communicating to Improve Quality
Strategy 4: Care Transitions
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pbrn.ahrq.gov/pqmp/measures/index.html
Measure Domain
Management of Acute Conditions
(54)
Overuse of Imaging
(8)
Transitions … (2)
Pediatric Intensive Care Unit (PICU)
(2)
Temperatures of Low Birthweight Neonates
(2)
Transitions … of Care)
(5)
Pediatric Oral Health
(2)
Health Outcomes
(1)
Patient Experience
(1)
Transitions
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pbrn.ahrq.gov/sites/default/files/wysiwyg/news/events/conference/2011/naylor/naylor.pptx
January 01, 2011 - Ware Professor in Gerontology
Director, NewCourtland Center for Transitions and Health
University of … Major Affordable Care Act Provisions
Center for Medicare and Medicaid Innovation
Community-Based Care Transitions … 0.620000000000002 0.42 0.29 0.2 Days
Mean No Rehosp Days
What do we know about effects of transitions … Hillman Foundation and the Jonas Center for Excellence
www.transitionalcare.info
The TCM…
Focuses on transitions … Drivers
At National Level
National goals, endorsed measures and public reporting platforms that focus on transitions
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pbrn.ahrq.gov/patient-safety/settings/ambulatory/index.html
July 01, 2022 - Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings is designed to help … staff actively engage patients and their care partners to prevent errors during transitions of care.
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pbrn.ahrq.gov/patient-safety/patients-families/index.html
June 01, 2023 - Medications at Transitions and Clinical Handoffs (MATCH) for Medication Reconciliation
Learn about the … The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
This toolkit … is designed to help staff actively engage patients and their care partners to prevent errors during transitions
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pbrn.ahrq.gov/pbrn-registry/rural-research-alliance-community-pharmacies
July 22, 2020 - high-quality implementation research with rural community pharmacies Current or Past Research Interests: Care transitions
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pbrn.ahrq.gov/news/funding-hais-carb.html
March 01, 2024 - all healthcare settings: long-term care, ambulatory care, acute care hospitals and those focusing on transitions
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pbrn.ahrq.gov/pbrn-registry/ambulatory-research-community-health-network
February 07, 2019 - Current or Past Research Interests: Behavioral health Care transitions Chronic pain Depression and other
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pbrn.ahrq.gov/whatsnew.html
April 01, 2024 - Models of Care (4/30/24)
Engaging Family Caregivers With Structured Communication for Safe Care Transitions
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pbrn.ahrq.gov/patient-safety/patients-families/patient-family-engagement/index.html
April 01, 2018 - Medications at Transitions and Clinical Handoffs (MATCH) for Medication Reconciliation
Learn about the … The Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings
This toolkit … is designed to help staff actively engage patients and their care partners to prevent errors during transitions
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/Ways_To_Learn_More_508.docx
May 21, 2013 - www.ipfcc.org
Improving discharge practices
BOOSTing (Better Outcomes for Older adults through Safe Transitions … ) Care Transitions resource room
These materials developed by the Society of Hospital Medicine to help … Available at: http://www.patientsafety.org/page/transtoolkit/
The Care Transitions Intervention
During … for improving patient- and family-centered care practices
Medication reconciliation
Medications at Transitions … Available at: http://www.ahrq.gov/legacy/fund/informedconsent/
Medications at Transitions and Clinical
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pbrn.ahrq.gov/news/newsroom/case-studies/201522.html
August 01, 2015 - using AHRQ's Re-Engineered Discharge (RED) Toolkit to reduce hospital readmissions and improve care transitions … evidence-based framework to help us develop a more comprehensive and appropriate discharge planning and care transitions
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pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.docx
April 01, 2011 - Planning (Implementation Handbook)
Strategy 4: IDEAL Discharge Planning (Implementation Handbook)
Care Transitions … program, and BOOSTing (Better Outcomes for Older Adults Through Safe Transitions) Care Transitions. … The Care Transitions Program, work on transitional care interventions with advanced practice nurses, … The BOOSTing (Better Outcomes for Older adults through Safe Transitions) Care Transitions project uses … The care transitions intervention: results of a randomized controlled trial.
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pbrn.ahrq.gov/hai/tools/clabsi-cauti-icu/implement/apic-cost-calculator.html
April 01, 2022 - Reducing CAUTI in Hospitals
Reducing CLABSI Toolkit
Safe Surgery Toolkit
Safe Transitions
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pbrn.ahrq.gov/ncepcr/communities/pbrn/registry/ambulatory-research-community-health-network.html
February 07, 2019 - Current or Past Research Interests / Health Conditions:
Behavioral health
Care transitions
Chronic
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pbrn.ahrq.gov/hai/tools/enhanced-recovery/choosing.html
June 01, 2023 - Reducing CAUTI in Hospitals
Reducing CLABSI Toolkit
Safe Surgery Toolkit
Safe Transitions
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pbrn.ahrq.gov/pbrn-registry/asthma-training-accelerate-communication-and-knowledge
April 07, 2014 - Medicine Network (at least 75% are Family Medicine Clinicians) Current or Past Research Interests: Care transitions
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pbrn.ahrq.gov/research/findings/making-healthcare-safer/comparison.html
September 01, 2022 - Drug Events in Older Adults
ADEs: Harms Due to Opioids
ADEs: Infusion Pumps
Alarm Fatigue
Care Transitions … Evidence
Alarm Risk Assessment
(Not reviewed)
(Not reviewed)
Summary of Evidence
Care Transitions … Patient Safety Practices
MHS I (2001)
MHS II (2013)
MHS III (2020)
Interventions To Improve Care Transitions … reviewed)
Summary of Evidence
(Not reviewed)
BOOST: Better Outcomes for Older Adults Through Safe Transitions