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.
Links/Resources/Tools for Providers
Formal Multidimensional Programs to Improve Care Transitions:
Care Transitions InterventionSM
Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure their needs are met during the transition from the acute care setting to home.Bridging Nursing Support / Transitional Care Model
Multidisciplinary, comprehensive in-hospital planning and home follow-up. Transitional Care Nurses follow patients from the hospital into the home to provide services designed to streamline plans of care, interrupt patterns of frequent acute hospital and emergency department use and prevent health status decline.Better Outcomes for Older Adults through Safe Transitions (BOOST)
Toolkit for improving hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific Interventions and written discharge Instructions.Best Practices Intervention Package (BPIP) Transitional Care Coordination
Comprehensive manual for home health agency leadership and staff to identify tools and processes to improve patient transitions; focus on the four pillars, or conceptual domains, of patient transition; includes tools and resources for patients and staff, guidelines and podcasts.Interventions to Reduce Acute Care Transfers (INTERACT)
Toolkit for SNF personnel to reduce avoidable hospital admission. Three types of tools: 1) communication; 2) clinical care paths; and 3) advance care planning. Utilization specified for selected members of the care team. Newly revised INTERACT II tools can help reduce avoidable acute care transfers.State Action on Avoidable Hospitalizations (STAAR)
The Institute for Healthcare Improvement (IHI) STAAR initiative aims to reduce rehospitalizations by working across organizational boundaries in four states - Massachusetts, Michigan, Ohio, and Washington - and by engaging payers, state and national stakeholders, patients and families, and caregivers at multiple care sites and clinical interfaces.Re-engineered Discharge (RED)
Standardized discharge intervention; includes patient education, comprehensive discharge planning, post-discharge telephone reinforcement.
Additional Links/Resources/Tools:
Eldercare Locator
A public service of the U.S. Administration on Aging connecting you to services for older adults and their families.Home Health Quality Improvement National Campaign
The Home Health Quality Improvement (HHQI) National Campaign is a grassroots movement designed to unite home health stakeholders and multiple health care settings under the shared vision of reducing avoidable hospitalizations and improving medication management. Participants and supporters can access free online tools and resources on the website, including Best Practice Intervention Packages. These resources are designed to unite providers across settings under the shared vision of reducing avoidable hospitalizations and improving medication management.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.Hospital to Home (H2H) National Quality Initiative
Co-sponsored by the American College of Cardiology (http://www.acc.org/) and the Institute for Healthcare Improvement (http://www.ihi.org/ihi). H2H is an effort to improve the transition from inpatient to outpatient status for individuals hospitalized with cardiovascular disease. This site is the home of the H2H initiative, and serves as a national clearinghouse of best practices, tools, and strategies related to the transition process for cardiovascular patients. Enroll now (http://www.acc.org/h2h/Enrollment/RequestForInfo.aspx) to join a community of health care providers that are committed to improving care.Speak Up Initiative
The Joint Commission, together with the Centers for Medicare and Medicaid Services, launched a national campaign to urge patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. The program features brochures, posters and buttons on a variety of patient safety topics.Ask Me 3TM
Patient education program designed to promote communication between health care providers and patients in order to improve health outcomes.Health Literacy Manual
Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words.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.Advance Care Planning: Preferences for Care at the End of Life
Research can help physicians and other health care professionals guide patient decision making for care at the end of life. Findings resulting from research funded by the Agency for Healthcare Research and Quality are discussed.Health Information in Multiple Languages
MedlinePlus, a service of the U.S. National Library of Medicine and the National Institutes of Health, has a multilingual feature that provides access to high quality health information for patients in 40 languages. This collection contains more than 2,500 links to nearly 250 health topics.The Dartmouth Atlas of Healthcare
This website provides access to all Atlas reports and publications, as well as interactive tools to allow visitors to view specific regions and perform their own comparisons and analyses. For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians.Why not the Best? A health care quality improvement resource
Tool for providers, consumers and researchers to see how well U.S. hospitals perform on measures of evidence-based care, patient experience, readmission and mortality rates, and costs.National Transitions of Care Coalition (NTOCC)
NTOCC has brought together thought leaders and representatives of different practice and professional settings studying the transitional challenges and identifying tools which can help improve transitions of care. Working together we can reduce transitional problems and ensure patient safety.Center to Advance Palliative Care: Palliative Care Tools, Training & Technical Assistance
The Center to Advance Palliative Care (CAPC) provides health care professionals with the tools, training and technical assistance necessary to start and sustain successful palliative care programs in hospitals and other health care settings.