Transitions of Care

Organization Websites

www.ntocc.orgFounded 2006 by Case Management Society of America (CMSA) & Sanofi US. Tools/resources for health care professionals (HCP) and consumers. Best practice to enhance transitions of care. Links to other sites, public policy, media, etc. Free and fee-based information. Affiliation w/ NASW. Appears to be an interdisciplinary site. Links to other sites as well.Dedicated to improving care coordination and the quality of Transitions of Care. Foundation for Medical Care (CFMC) serves as the National Coordinating Centers for the Integrating Care for Populations & Communities (ICPC). NCCs support CMS & its network of 53 QIOs (Quality Improvement Organizations). Focuses on community based projects & partnerships for care transitions. Tools/resources for HCP & consumers. With latter includes End of Life Planning (i.e. Adv Dir, Palliative care, hospice).Leadership in Health Care Improvement Science
www.stratishealth.orgNonprofit organization focusing on quality improvement; works w/ HCPs and consumers. Initially formed in 1971 (Foundation for Health Care Evaluation), group of physicians; 1997 merged w/ Health Outcomes Institute – Stratis Health. Medicare QIO for MN. Role includes: quality improvement expert & clearing house; educator & trainer; consultant & supporter; facilitator & convener; data resource & management and consumer resource w/ focus on navigating hc system.Leading collaboration and innovation in health care quality and safety (IT focus/ consultation)
www.caretransitions.orgDr. Eric Coleman’s work. Excellent resource on Care Transitions, tools, resources and implementation for HCP & consumers.
APN – as Transition Coach
Health care services for improving quality and safety during care hand-offs will it take.aspDescribes 7 strategies “that collectively hold promise for ensuring high quality transitional care”:

  • Foster greater engagement of pts. & family caregivers
  • Elevate the status of family caregivers as essential members of care team
  • Implement performance measurement
  • Define accountability during transitions (references Transitions of Care consensus Policy Statement)
  • Build professional competency in care coordination
  • Explore technological solutions to improve cross setting communication
  • Align financial incentives to promote cross setting collaboration.
This is an article on the care transitions website, not a site unto itself. The mission of the care transitions website is listed above.
Society of Hospital Medicine urceroomredesign/rr- caretransitions/ct_home.cfm
BOOST website, providing a QI process for improving transitions. Assessment tools, check lists, forms. Primary objective: identify high-ris patient on admissions, reduce 30-day readmits, reduce LOS, increase satisfaction & HCAHPS scores; increase information flow between in/outpatient providers. Encouraged use of “hospitalist nurse” to conduct fu phone calls to dc’d patients.We promote exceptional care for hospitalized patients.
Joint Commission
Portal to Transitions of Care, with links government and professional organizations
See itself as a valuable resource in assuring safe transitions
Very medically driven
Provides guidance in how to be certified or accredited as an expert in TOC Available articles on safe transitions
Identifies nursing as having a role in the medical home
To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
HI: owtoguidei.aspx
Excellent description of varied roles in transitions;
How to guide for improving transitions from hospital to community settings to reduce avoidable admissions.
Clearly identifies a role for a community based player
Guide includes:

  • Getting Started: steps to get started on creating an ideal transition for patients being discharged from the hospital, a post-acute care setting, or a rehabilitation facility.
  • Key Changes: Four key recommendations for improving the transition out of the hospital
  • Infrastructure and Strategy to Achieve Results
  • Case Studies:
  • Measures, Resources, and References:

Also includes how to guides for improving transitions from the hospital to a) clinic practice, b) skilled nursing facilities, and c) home health

To be a recognized and generous leader, a trustworthy partner, and the first place to turn for expertise, help, and encouragement for anyone, anywhere who wants to change health care profoundly for the better.
Health Care Transitions
Both of these websites, the first out of University of Florida, and the second from NIH, provide guidance for supporting the life transitions of pediatric patients to adulthood. Not related to health care transitionsThe mission of the Health Care Transition Initiative at the University of Florida is to increase awareness of, gain knowledge about, and promote cooperative efforts to improve the process transitioning from child-centered (pediatric) to adult oriented health care.
Transitions from pediatric to adult health care
Public and private partners in efforts to improve diabetes management and outcomes, promote early diagnoses, and prevent or delay the onset of diabetes in the United States and its territories.
NDEP’s goal is to reduce the burden of diabetes and prediabetes by facilitating the adoption of proven approaches to prevent or delay the onset of diabetes and its complications.
Case Management Society of America
To be the leading membership association providing professional collaboration across the healthcare continuum to advocate for patients’ wellbeing and improved health outcomes by fostering case management growth and development, impacting health care policy, and providing evidence-based tools and resources.
American Case Management Association
To be THE association for Hospital / Health System Case Management professionals.
American Association of Colleges of Nursing

The American Association of Colleges of Nursing (AACN) is the national voice for academic nursing education. AACN works to establish quality standards for nursing education; assists schools in implementing those standards; influences the nursing profession to improve health care; and promotes public support for professional nursing education, research, and practice.

American Nurses Association
Has issues panel on care coordination quality measures. All relevant information related to the ANA and AAN work on care coordination can be accessed through the following link:
ANA’s Care Coordination Statement (2012): ANA Urges Recognition and Funding for Nurses’ Essential Role in Patient Care Coordination
Nurses advancing our profession to improve health for all.
Agency for Healthcare Research and Quality
Improve the quality, safety, efficiency, and effectiveness of health care for all Americans.