-
www.ahrq.gov/patient-safety/reports/engage/appe.html
March 01, 2017 - Environmental Scan Report
Safety Issues
Fragmentation of the care systems and transitions
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/engagingfamilies/howtogetstarted/How_to_Use_Guide_Ldr_Slide_508.pdf
April 02, 2025 - Working with Patients and Families at the Bedside:
Care Transitions from Hospital to Home:
IDEAL … • Transitions in care have potential for medical errors
• Research shows bedside shift report can improve
-
www.ahrq.gov/sites/default/files/publications/files/pocketguide.pdf
January 01, 2020 - Communication
Handoff
The transfer of information (along with
authority and responsibility) during
transitions … Examples of transitions in care include
shift changes; transfer of responsibility
between and among … transfers.
13
Communication
Handoff
Strategy designed to enhance information exchange
during transitions
-
www.ahrq.gov/patient-safety/settings/hospital/resource/guide/web1.html
December 01, 2017 - Community-based Care Transitions Program.
Transitional Care Management Billing Codes.
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/asthma-training-accelerate-communication-and-knowledge.html
April 07, 2014 - Network Founded:
2014
Current or Past Research Interests / Health Conditions:
Care transitions
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/community-care.html
January 01, 2013 - Current or Past Research Interests / Health Conditions:
Care transitions
Children's health issues
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/better-health-partnerships.html
March 27, 2015 - Interests / Health Conditions:
Cardiovascular disease, including stroke and hypertension
Care transitions
-
www.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
-
www.ahrq.gov/cpi/about/organization/nac/kripalani.html
February 01, 2025 - Kripalani is internationally recognized for his expertise in improving transitions of care for hospital
-
www.ahrq.gov/patient-safety/settings/hospital/red/toolkit/redtool6ref.html
March 01, 2025 - Care Transitions Performance Measurement Set. Centers for Medicare & Medicaid Services (CMS).
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/clinical-nurse-leader-research-collaborative.html
October 17, 2016 - Current or Past Research Interests / Health Conditions:
Care transitions
Comparative effectiveness
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/consortium-southeastern-hypertension-control.html
March 12, 2015 - Interests / Health Conditions:
Cardiovascular disease, including stroke and hypertension
Care transitions
-
www.ahrq.gov/data/hcup/sepsis-state-hospital.html
March 01, 2025 - Hospital and emergency department costs for sepsis Hospital readmissions for sepsis Post-acute care transitions
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3_communication.pptx
July 01, 2023 - and clinical practice, you will find check-backs are particularly helpful:
During handoffs and care transitions … Use a structured communication strategy like SBAR during these transitions and confirm that you have … It can be used to structure a general conversation or patient care transitions. … Care transitions and handoffs (e.g., during shift changes)
Requesting a response during emergent events … status, especially those related to early-warning signs Use SBAR to:
Structure communications, care transitions
-
www.ahrq.gov/sites/default/files/wysiwyg/hai/tools/perinatal-care-2/hypertension_3-communication-speaker-notes.pdf
July 01, 2023 - Hospital AIM
Team
Leads
SPPC‐II
Opportunities To Check‐Back
• During handoffs and care transitions … clinical practice, you will find check‐backs are
particularly helpful:
• During handoffs and care transitions … Use a structured communication strategy
like SBAR during these transitions and confirm that you have … It can be used to
structure a general conversation or patient care transitions. … • Care transitions and handoffs
(e.g., during shift changes)
• Requesting a response during
emergent
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/primary-care/workforce-financing/case_example_6.pdf
October 01, 2016 - ..............................................................................3
Care Coordination/Transitions … Care Coordination/Transitions and Care Management
HFHS has a staffed central call center for all physicians … Care managers are primarily focused on
transitions of care, with some management for diabetes care, … As part of the residency training program, the K-15 clinic runs a Transitions of Care clinic as a
bridge … The transitions clinic sees
patients transitioning out of the emergency room (ER), observation or inpatient
-
www.ahrq.gov/patient-safety/reports/engage/strategies.html
April 01, 2018 - Supports handoff within the practice to reduce communication drops during transitions.
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/florida-state-university-college-medicine-network-clinical-research-and-training.html
October 18, 2016 - Interests / Health Conditions:
Cardiovascular disease, including stroke and hypertension
Care transitions
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/central-ohio-practice-based-research-network.html
January 01, 2012 - Interests / Health Conditions:
Cardiovascular disease, including stroke and hypertension
Care transitions
-
www.ahrq.gov/ncepcr/communities/pbrn/registry/developmental-disabilities-pbrn.html
June 07, 2013 - Current or Past Research Interests / Health Conditions:
Behavioral health
Care transitions
Coordination