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www.ahrq.gov/sites/default/files/publications/files/caremgmt-brief.pdf
April 01, 2015 - It is well understood that poorly executed transitions of care between different locations (e.g.,
from … present
the greatest risks and targeting CM services to patients undergoing those transitions should … Promoting effective transitions of care at hospital
discharge: a review of key issues for hospitalists … Impact of an integrated transitions management
program in primary care on hospital readmissions. … Preparing patients and caregivers to participate in care delivered
across settings: The Care Transitions
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www.ahrq.gov/patient-safety/settings/hospital/index.html
February 01, 2025 - 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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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-5.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter … Education and Training
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Medications at Transitions … Communicating medication information during transitions in care. … developing good communication patterns regarding patients' medication information during handoffs and transitions
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www.ahrq.gov/ncepcr/care/coordination/atlas/appendix1.html
June 01, 2014 - [Measure #12b, item I-4 (ICU Nurse-Physician Questionnaire)]
Facilitate Transitions †
Across Settings … Transitions from hospital to home are mapped to Inpatient Facility and Primary Care Facility, since … † Note 2: We were able to map all measures related to transitions to one or the other of the subdomains … specifying transition type ( Facilitate Transitions Across Settings and Facilitate Transitions as Coordination … Therefore, no measures or measure items were mapped to the less specific Facilitate Transitions domain
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www.ahrq.gov/practiceimprovement/delivery-initiative/abstract-magill.html
December 01, 2017 - care managers in 9 of the organization's 10 primary care clinics, along with the implementation of transitions … management services delivered by the care managers and a pilot transitions navigator role at the University
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/strategy4/Strat4_Implement_Hndbook_508_v2.pdf
April 01, 2011 - IDEAL Discharge Planning (Implementation Handbook)
Guide to Patient and Family Engagement
Care Transitions … Interested in
improving transitions
from hospital to home? … program, and BOOSTing (Better
Outcomes for Older Adults Through Safe Transitions) Care Transitions … 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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www.ahrq.gov/patient-safety/settings/hospital/match/figure-9.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Figure … Patient Medication Interview
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Medications at Transitions
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www.ahrq.gov/teamstepps-program/curriculum/communication/tools/ipass.html
July 01, 2023 - Tool: I-PASS
I-PASS has become the preferred handoff tool for patient transitions in many
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www.ahrq.gov/patient-safety/settings/hospital/match/appendix/app-7.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Appendix … Medication Reconciliation
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Table of Contents
Medications at Transitions
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www.ahrq.gov/teamstepps-program/curriculum/communication/overview/index.html
June 01, 2023 - A standardized method for transferring information (along with authority and responsibility) during transitions … I-PASS
I-PASS is the preferred handoff tool for patient transitions in care in many organizations.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/multichronic/funded-resources.html
November 01, 2021 - Notice of Funding Opportunities
Improving Quality of Care and Patient Outcomes During Care Transitions … information technology (IT) interventions aimed at improving communication and coordination during care transitions … these studies will lead to new approaches to use interoperable health IT innovations to improve care transitions
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www.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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www.ahrq.gov/action-alliance/resources/type-harm.html
April 01, 2025 - Safety Medication Safety Never Events Opioid Safety Pressure Ulcers Readmissions Sepsis Surgical Safety Transitions … AHRQ Medications at Transitions and Clinical Handoffs (MATCH) This resource features strategies from … Back to Contents Transitions in Care AHRQ Questions Are the Answer This resource includes materials to … AHRQ 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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www.ahrq.gov/news/newsroom/case-studies/cquips0605.html
October 01, 2014 - The lowest areas were for "non-punitive response to error" and "hospital handoffs and transitions." … Patient handoffs and transitions were already being addressed, but the focus will continue to improve
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www.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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www.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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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/connecting-dots-100813.ppt
January 01, 2013 - 12 composites have at least 1 reverse-worded item
2 Composites all items reverse-worded
Handoffs & Transitions … *
Four items elicit perceptions of handoffs & transitions. … Hospital Handoffs & Transitions Hospital Handoffs & Transitions
ICU State Average
Your Unit's Results … Management Support for Safety 61% 74%
Teamwork Across Hospital Units 56% 66%
Hospital Handoffs & Transitions … Hospital Handoffs & Transitions Hospital Handoffs & Transitions
Your Unit's Nurse Results (n= )
Your
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www.ahrq.gov/ncepcr/reports/grants-impact/model-state.html
February 01, 2017 - IMPaCT grant funded two collaboratives: the Regional Leadership Collaborative and the Primary Care Transitions … Staff from nine primary care practices participated in the Care Transitions Leadership Collaborative. … Each practice established a Care Transitions Improvement Team comprised of at least one physician champion … health care providers from nine practices to strengthen regional leadership and QI capacity and improve transitions … The small projects funded through the CHIOs focused on depression, diabetes, opioid management, care transitions
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www.ahrq.gov/patient-safety/settings/hospital/match/chapter-6.html
July 01, 2022 - Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation
Chapter … Assessment and Process Evaluation
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Medications at Transitions … Auditing should be done at all the transitions of care and should include each discipline involved in
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www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamilyapc.html
July 01, 2018 - Health
National Patient Safety Agency (United Kingdom)
National Patient Safety Foundation
National Transitions … Foundation
Save the Patient
Society of Critical Care Medicine
State hospital associations
The Care Transitions