The National Coordinating Center (NCC) for the Integrating Care for Populations and Communities Aim (ICPCA) assists Medicare Quality Improvement Organizations (QIOs) to promote seamless transitions between health care settings.
The ICPCA NCC Learning Sessions are back in session!
Check out the Learning Sessions page for upcoming calls and recordings of all of the past calls.
Patient Resources
Managing your Health and Planning for Safe Transitions:
How to Avoid the Round-Trip Visit to the Hospital
Carolyn M. Clancy, M.D., Director of the Agency for Healthcare Research and Quality (AHRQ), offers brief, easy-to-understand advice columns for consumers to help navigate the health care system. In her latest column, Dr. Clancy highlights the steps patients and their family members/caregivers can take to prevent an unnecessary return trip to the hospital.Ask Medicare
The Ask Medicare initiative provides information, tools and materials to assist the caregiver and their loved ones in making informed healthcare decisions.The Care Transitions ProgramSM Personal Health Record (PHR)
A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition. Print out the PHR, personalize it by filling in your information, and take it with you to all medical visits. Be sure to share the PHR with your doctors and nurses, asking them the questions you have written and updating them on any changes in your medicationsNext Step in Care
This website provides information and advice to help family caregivers and health care providers plan safe and smooth transitions for patients. Transitions occur when patients move from one care setting to another, for example, from a hospital to home or rehab facility, or when home care agency services start and end. Patient transitions are often complicated, rushed, and beset by errors or misunderstandings.Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Be Prepared for Medical Appointments
Successfully prepare for doctor’s visits with this easy-to-read, two-page brochure that outlines questions to ask and simple steps to take.Questions are the Answer
Clinicians, the Government, and many other groups are working hard to improve health care quality, but it's a team effort. You can improve your care and the care of your loved ones by taking an active role in your health care. Ask questions. Understand your condition. Evaluate your options.National Transitions of Care Coalition (NTOCC)
NTOCC has brought together industry leaders who have created resources to help you better understand transitional challenges and empower you as part of the care giving team.Additional resources, including book recommendations can be found on The Care Transitions ProgramSM website.
MedlinePlus: Interactive Health Tutorials
This website contains many tutorials which are interactive health education resources from the Patient Education Institute. Using animated graphics each tutorial explains a procedure or condition in easy-to-read language. You can also listen to the tutorial.
Preparing for your Hospital Stay/Discharge:
Care About Your Care: Tips for Patients When they Leave the Hospital
This 4-page article will help you LOOK at the care you get and understand what good care for patients who are leaving the hospital looks like, help you LEARN what you can do to make sure you get the best possible care, and help you LIVE better by taking action to get better care.Taking Care of Myself: A Guide for When I Leave the Hospital
Taking Care of Myself: A Guide for When I Leave the Hospital is a guide for patients to help them care for themselves when they leave the hospital. The easy-to-read guide can be used by both hospital staff and patients during the discharge process and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.Navigating the Health Care System
AHRQ Director Carolyn Clancy, M.D., has prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system. They will address important issues such as how to recognize high-quality health care, how to be an informed health care consumer, and how to choose a hospital, doctor, and health plan. Check back regularly for new columns.20 Tips to Help Prevent Medical Errors
The single most important way you can help to prevent errors is to be an active member of your health care team. That means taking part in every decision about your health care. Research shows that patients who are more involved with their care tend to get better results. Here are some specific tips, based on the latest scientific evidence about what works best.The Care Transitions ProgramSM Discharge Preparation Checklist
A structured checklist of critical activities designed to empower patients. Before you leave the hospital or nursing facility, be sure you have completed each of the tasks on the checklist. Talk to your doctors and nurses about what is going to happen next, find out who you should call if there are problems with your transfer or medications, and be sure you understand how to take your medications. Write down important information and the answers to your questions in your Personal Health Record.CMS Discharge Planning Checklist
The Centers for Medicare & Medicaid Services (CMS) has developed a checklist that prompts patients and caregivers to ask questions about key discharge planning topics including their likely care needs, the options for continuing care, post-discharge care instructions, community-based resources, and more. The checklist is intended to encourage patients and caregivers to actively participate in the discharge planning process and reflects CMS' goal to achieve high-value, person-centered health care. Providers can make use of the checklist by: (1) making staff aware of the checklist; (2) including it in pre-administration and/or admission paperwork; and, (3) by encouraging staff to work with patients and caregivers to complete the checklist.Administration on Aging Website
The Administration on Aging is website provides the following off-site resources to connect older persons, caregivers and professionals to important federal, national, and local programs: eldercare locator, benefits checkup, useful topic-specific resources for older adults, caregivers and aging professionals, and long-term care planning.
End of Life Planning:
The Palliative Care Policy Center (PCPC)
Offers expert support to hospitals, nursing homes, health systems, hospices, and other organizations that serve individuals nearing the end of life. We seek to help you make breakthrough change happen in areas that matter to patients and families. A key goal of our activities is to gather information and create a common database that can help improve the experience of dying patients and their families everywhere. We make our findings and lessons learned available to all so that all who aim to improve care for serious illness may succeed.Comprehensive End of Life Resources
Comprehensive resource page sponsored by the U.S. National Library of Medicine and the National Institutes of Health which contains links to many useful materials for both patients or caregivers faced with planning end-of-life of care.American Bar Association Consumer’s Tool Kit for Health Care Advance Planning
The Consumer's Tool Kit for Health Care Advance Planning contains self-help worksheets, suggestions and resources to help patients and families clarify and communicate their priorities in the face of serious illness.AARP: Advance Directives: Planning for the Future
Do you know what your loved one's health care wishes are at the end of life? Find out how advance directives can help.
AARP: Talking about your Final Wishes
This article on the AARP site offers suggestions on starting the conversation with your family and loved ones about your end-of-life wishes.
National Hospice and Palliative Care Organization: Caring Connections
Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO), is a national consumer and community engagement initiative to improve care at the end of life.