Care Transitions

Transforming Care at the Bedside: How-to Guide for Creating an Ideal Transition Home for Patients with Heart Failure - a program developed by the Institute for Healthcare Improvement

Reducing Readmissions through Transitions in Care - Presentation by Dr. Amy Boutwell, IHI

Transition "Tickets" Reduce Adverse Events During Patient Transports - Summary: University of Pittsburgh Medical Center (UPMC) Presbyterian Hospital developed an intra-hospital transport ticket (known as Ticket to Ride) that accompanies patients from their "home" inpatient unit to any diagnostic testing and procedural areas they may need to visit and then back again to the home unit. The ticket is designed to standardize the intra-hospital inpatient transport process by providing critical patient information and a checklist of steps to ensure patient safety during transport and accurate care at each destination. The program has led to significantly fewer off-unit adverse events and higher levels of patient satisfaction with the transportation process.

Transition Home Program Reduces Readmissions for Heart Failure Patients - Summary: The Transition Home for Patients with Heart Failure program at St. Luke’s Hospital in Cedar Rapids, IA, incorporates a number of components to ensure patients a safe transition to home or another health care setting. These components include enhanced assessment of post-discharge needs at admission, thorough patient and caregiver education, patient-centered communication with subsequent caregivers at handoffs, and a standardized process for post-acute care followup. The program reduced the 30-day readmission rate for heart failure pateints from 14 percent to 6 percent.

Care Transitions for Older Adults/BOOST - (Better Outcomes for Older adults through Safe Transitions) care transitions resource room from the Society of Hospital Medicine (SHM) provides materials to help optimize the discharge process.

CMS News: Medicare Announces Sites for Pilot Program to Improve Quality as Patients Move Across Care Settings - Miami was one of the sites chosen for the Medicare Care Transitions pilot program. Susan Stone from FMQAI presented information on this at the January Collaborative meeting (see slide presentation). More about the project is on FMQAI's Web site and the Care Transitions Web site.

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