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Administration for Community Living

ADRCs have been working to assist individuals in “critical pathways,” defined as the times or places when people make important decisions about long-term care.

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BOOST - Better Outcomes by Optimizing Safe Transitions

A National initiative led by the Society of Hospital Medicine to improve the care of patients as they transition from hospital to home.

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BOOST Overview

An overview of the BOOST (Better Outcomes by Optimizing Safe Transitions) toolkit.

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BPIP - Best Practice Intervention Packages

From HHQI, guidelines related to cardiovascular risk assessment and management. Updates to each Cardiovascular Health BPIP have been added to the list of resources. Each Update is intended to be used in conjunction with its corresponding Cardiovascular Health BPIP.

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Chronic Obstructive Pulmonary Disease (COPD) Self-Management Tool

“My COPD Action Plan” is a self-management tool to help patients understand what to do with symptom exacerbation. Patients should bring this form to each doctor’s appointment and update as needed.

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CMS Discharge Planning Checklist

Discharge planning checklist for hospital staff to discuss discharge planning with every patient that has a scheduled admission.

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CMS Overview of CT Programs

Resources for readmissions and care transitions. Partnership for Patients, Project RED. CTP, Project BOOST, TCM Overview, STAAR, and GRACE.

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Collective Impact

To create lasting solutions to social problems on a large-scale, organizations need to coordinate their efforts and work together around a clearly defined goal. Find resources, tools, training and the latest news.

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INTERACT - Interventions to Reduce Acute Care Transfers

A quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in every day practice in long-term care facilities.

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Interventions from NCOA

Patients with complex care needs and family caregivers receive specific tools and work with a “Transitions Coach,” to learn self-management skills. This is a low-cost, low-intensity intervention comprised of a home visit and three phone calls.

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Medication Tracker Pocket Card

As part of the Million Hearts campaign, this tracker card was created so patients could list the medications they take and bring the card with them when they visit their physician or pharmacist.

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Post-Discharge Tool

This tool, from the National Patient Safety Foundation (NPSF), provides helpful tips about readmissions as well as an easy-to-use post-discharge tool.

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RED - Re-Engineered Discharge

The RED intervention is founded on 12 discrete, mutually-reinforcing components and has been proven to reduce rehospitalizations.

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The Care Transitions Program

Targeted for those who are discharged from hospital to home and provides a Transition Coach who focuses on medication self-management, the patient-centered medical record, follow-up appointments, and red flags. Transition Coaches can be incorporated into home health agencies’ model of care.

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