Leading Change: Community Healthcare Outcomes Resources

Agency for Healthcare Research and Quality (AHRQ) at US DHHS
AHRQ has a series of toolkits with information related to care transitions and patient safety. Toolkit topics include: Handoffs, Discharge, Medication Reconciliation, Work Processes, etc. These resources are at: http://www.ahrq.gov/qual/pips/issues.htm

Better Outcomes for Older Adults through Safe Transitions (Project BOOST) at Society of Hospital Medicine
BOOST aims to improve the care of patients as they transition from hospital to home. It has a particular focus on older adults. It addresses readmission rates, patient satisfaction, information flow to outpatient physicians and teach-back practices for patient and family education. More information is at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home&CONTENTID=27659&TEMPLATE=/CM/HTMLDisplay.cfm

The Care Transitions Program at University of Colorado Denver, (Eric Coleman)
The Care Transitions Program addresses patients with complex care needs with specific tools, including discharge preparation, a “transition coach” component, and training for self-management skills. More information is at: http://www.caretransitions.org/provider_tools.asp

Re-Engineered Discharge (Project RED) at BU/Boston Medical Center
The RED intervention is founded on 11 discrete, mutually reinforcing components and has been demonstrated a reduction in re-hospitalizations and supports high rates of patient satisfaction. More information is at: https://www.bu.edu/fammed/projectred/

Transitional Care Model (TCM) at University of Pennsylvania School of Nursing
TCM is a nurse-led model for follow-up care for chronically ill high-risk older adults in the hospital common medical or surgical conditions. It includes a multi-disciplinary team using tested protocols. More information is at: http://www.transitionsalcare.info/