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Care Coordination

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Heart Failure

AHA Toolkit for Professionals

Discover patient education tools from the American Heart Association. Sources include a Go-to-Guide, Heart Failure Patient Education Checklist, Heart Failure Signs and Symptoms, and more.



Discharge Checklist

A Target Heart Failure discharge checklist tool.



Medication Management

8Ps Risk Assessment Tool

From the Society of Hospital Medicine, this screening tool helps to identify a patient's risk for adverse events after discharge and screens for (1) problems with medications, (2) psychological issues, (3) principal diagnosis, (4) physical limitations, (5) poor health literacy, (6) patient support, (7) prior hospitalizations, and (8) palliative care.



BPIP Medication Management Package

The Best Practice Intervention Package (BPIP) includes a successful medication management program that encourages providers to work across settings, uses an interdisciplinary approach, and applies patient-centered teaching methods. This focused BPIP provides patient-friendly tools to improve health literacy and includes a tool and resource guide as well as a clinician guide.

Note: The Home Health Quality Improvement (HHQI) website requires registration to access this document.



Reports and Articles

Center for Healthcare Research and Transformation

Policy paper on care transitions: Best practices and evidence-based programs.



Coleman Care Transitions Intervention

To improve patient transitions from one care setting to another, CHCF funded the implementation of the Coleman Care Transitions Intervention in 10 California communities.



Teach-Back

Always Use Teach-Back

The purpose of this training toolkit "Always Use Teach-Back," found at www.teachbacktraining.org, is to help healthcare providers learn to use teach-back to support patients and families throughout the care continuum, especially during transitions between healthcare settings. The toolkit combines health literacy principles of plain language and using teach-back to confirm understanding, with behavior change principles of coaching to new habits and adapting systems to promote consistent use of key practices.



Always Use Teach-Back 10 Elements of Competency for Using Teach-Back Effectively

Part of the "Always Use Teach-Back" toolkit, this sheet give pointers on effective teach-back communication.



Tools and Guides

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.



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.



Zone Tools for Patients

Asthma - English

Zone Tool for Asthma (English)



Asthma - Spanish

Zone Tool for Asthma (Spanish)