| | | | Care Transitions: Resources and Links  Acute Care and Psychiatric Facility Change Package | Introduces eight categories of potential interventions suitable for Acute Care and Psychiatric Facilities: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions.
Last Updated: December 2008 Size: 62.61 Kb
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| Dialysis Center Change Package | Introduces eight categories of potential interventions suitable for Dialysis Centers: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions.
Last Updated: December 2008 Size: 53.75 Kb
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| Home Health Agency Change Package | Introduces eight categories of potential interventions suitable for Home Health Agencies: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions.
Last Updated: December 2008 Size: 75.1 Kb
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| Hospice Change Package | Introduces eight categories of potential interventions suitable for Hospices: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions.
Last Updated: December 2008 Size: 54.1 Kb
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| Skilled Nursing Facility and Rehabilitation Hospital Change Package | Introduces eight categories of potential interventions suitable for Skilled Nursing Facilities and Rehabilitation Hospitals: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions.
Last Updated: December 2008 Size: 65.47 Kb
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| Planning for Your Discharge (English Version) | The Centers for Medicare & Medicaid Services (CMS) has created a checklist for patients preparing to leave a hospital, nursing home, or other healthcare facility. Designed to be used by patients, family members, and caregivers, this checklist helps simplify what can be an overwhelming experience.
Last Updated: January 2009 Size: 484.08 Kb
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| Planning for Your Discharge (Spanish Version) | The Centers for Medicare & Medicaid Services (CMS) has created a checklist for patients preparing to leave a hospital, nursing home, or other healthcare facility. Designed to be used by patients, family members, and caregivers, this checklist helps simplify what can be an overwhelming experience.
Last Updated: January 2009 Size: 3.12 Mb
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INTERACT - Interventions To Reduce Acute Care Transfer in the Care Transitions 
Introduction to the INTERACT II Program
| The INTERACT II Program is designed to improve the quality of nursing home care by providing staff with tools and resources that will help to reduce avoidable acute care transfers.
Last Updated: January 2010 Size:
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Implementing INTERACT II Tools
| Use this guide to implement healthcare system changes that can be effective in improving patient care.
Last Updated: January 2010 Size:
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SBAR Communication Tool and Progress Note
| The purpose of SBAR is to improve communication between nurses and primary care providers by encouraging all healthcare team members to use the same language when communicating with one another.
Last Updated: January 2010 Size:
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| Cross-setting Interventions Overview | While some potential Interventions (Advance Care Planning, Patient and Family Education) are used across all healthcare settings, others (Disease Management, Fall Prevention) are applicable only under selected circumstances. This grid identifies 13 potential Interventions and the settings in which they might be employed.
Last Updated: November 2008 Size: 69.26 Kb
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| New Jersey Care Transitions Project Personal Health Record (PHR) (English Version) | While deceptively simple, PHRs can make a tremendous difference. A summary of a patient’s overall health, it includes a comprehensive list of medications. The very act of compiling PHRs gives patients a deeper understanding of their own health, allowing them to make informed decisions. This PHR, with large easy-to-read print, was designed especially for use by older adults. Typically, the medical records section is printed on bright green paper, while the medication section is printed on red. The booklet is folded, not stapled, allowing the insertion of updated information.
Last Updated: June 2009 Size: 66.65 Kb
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| New Jersey Care Transitions Project Personal Health Record (PHR) (Spanish Version) | While deceptively simple, PHRs can make a tremendous difference. A summary of a patient’s overall health, it includes a comprehensive list of medications. The very act of compiling PHRs gives patients a deeper understanding of their own health, allowing them to make informed decisions. This PHR, with large easy-to-read print, was designed especially for use by older adults. Typically, the medical records section is printed on bright green paper, while the medication section is printed on red. The booklet is folded, not stapled, allowing the insertion of updated information
Last Updated: September 2009 Size: 67.56 Kb
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| Provider Communication Workshop: Home Health Agencies and Emergency Departments | This workshop allowed project participants from home health agencies (HHAs) and hospital emergency departments (EDs) to share their experiences, successes and difficulties in reducing avoidable 30-day hospital readmissions. Attendees compiled a summary of barriers and potential solutions, in an effort to implement appropriate strategies that can help improve communication during transfers and reduce avoidable hospital readmissions.
Last Updated: March 2010 Size: 90.67 Kb
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| Provider Communication Workshop: Extended Care Facilities and Emergency Departments | This workshop allowed project participants from extended care facilities (ECFs) and key nursing staff from two hospital emergency departments (EDs) to discuss ways to improve communication regarding resident health status. Attendees compiled a summary of barriers and potential solutions, in an effort to implement appropriate strategies that can help improve communication during transfers and reduce avoidable hospital readmissions.
Last Updated: March 2010 Size: 90.76 Kb
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| New Jersey Care Transitions Project Launch Presentation | Andrew Miller, MD, MPH, is Co-Leader of the New Jersey Care Transitions Project. In this presentation, he examines 30-day hospital readmission rates among Medicare recipients, especially those with chronic medical conditions. He outlines the underlying causes behind high readmission rates, then introduces a national pilot project designed to reduce those rates through better communication across the continuum of healthcare settings. Healthcare Quality Strategies, Inc., (HQSI) is one of only 14 organizations nationwide selected by the Centers for Medicare & Medicaid Services (CMS) to participate in this pilot program.
Last Updated: November 2008 Size: 662.53 Kb
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| Improving Care Transitions Through Effective Communication | Marie Young is a nationally known Organization Development (OD) professional and practitioner. Her education and experience is focused on people performance at the individual, team, department, and corporate levels. In this presentation, she looks at the role of communication in the healthcare process. She identifies common barriers to effective communication, as well as strategies to overcome them. She pays particular attention to hospitals and other heathcare settings, with a special emphasis on issues impacting the New Jersey Care Transitions Project.
Last Updated: November 2008 Size: 1.01 Mb
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Health Care Leader Action Guide to Reduce Avoidable Readmissions
| This guide, developed by the Health Research & Education Trust (HRET), an affiliate of the American Hospital Association (AHA), is designed to serve as a starting point for hospital leaders to assess, prioritize, implement, and monitor strategies to reduce avoidable readmissions. A four-step approach is detailed, beginning with examining your hospital’s current rate of readmissions and concluding with monitoring your hospital’s progress.
Last Updated: March 2010 Size:
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