Quality Insights of Pennsylvania

Resources

The following resources assist Care Transitions Project participants in coordinating patient care across settings.

	Introduction Resources		Web Sites
	Maps		Newsletter
	Intervention Resources		Multimedia (audio, video)

Introduction Resources

These two resources introduce the Care Transitions project to participants and to others who may be interested in coordinating care across settings.

• Care Transitions Introduction Package
• Care Transitions Brochure

Download the materials from the Care Transitions Kick-off meeting (held November 10, 2008):

• Care Transitions Kick-off Binder
   

The following maps outline the Pennsylvania Care Transitions Community as well as the Care Transitions Projects currently taking place across the country.

• Pennsylvania Care Transitions Community
• National Care Transitions Communities
   

Intervention Resources

The resources in this section are available to assist participants in the Care Transitions Project with assessing their current processes relating to improving care across settings.

• The Four Pillars
• ACH Connection
• Excela Health System Cross-Setting Transfer Form

This form outlines the steps to take in preparing for and implementing your Care Transitions interventions.

• Next Steps

• In-Patient Facility Interventions
• Skilled Nursing Facility Interventions
• Home Health Agency Interventions

Use the following forms to report your facility or agency process of care investigation findings as well as indicate the interventions you will implement in your facility or agency.

• In-Patient Facility Process of Care Tool
• Skilled Nursing Facility Process of Care Tool
• Home Health Agency Process of Care Tool

NEW The following PowerPoint presentations were presented at the May 2009 Learning Session. Various participating providers presented the interventions they've chosen to implement and how they went about incorporating them into their processes.

Cross-Setting Transfer Form
The Excela Cluster collaboratively developed this presentation to explain how they plan to implement a cross-setting transfer form.

Care Transitions Discharge/Transfer Nursing Summary
UPMC Jefferson Regional Home Health of the McKeesport Cluster discusses how to implement a nursing summary form to assist with transitions.

CHF/PCH 48-hour Follow-up
The McKeesport Cluster developed this presentation to discuss follow-up protocol for CHF patients.

CHF Case Manager Role
Mon Valley Hospital discusses what role the CHF Case Manager plays in care transitions.

Transition of Care
Kane Regional Center of the McKeesport Cluster discusses various interventions, such as SBAR and POLST and ways to implement them in order to assist with the transition of care.

SBAR Implementation
Harmon House Care Center discusses how to implement the Situation-Background-Assessment-Recommendation (SBAR) tool.

Care Transitions - Heart Failure Program
Excela Health - Latrobe Hospital discusses the Heart Failure Program they have in place.

The following zipped file is the Care Transitions Toolkit. The toolkit is a collection of resources intended to help with the care transitions process and implementations. (Note: This file is very large. Right-click on the link and "Save Target As..." for best results. In order to keep the intended folder structure, once the .zip file is downloaded 1. right-click on the file and select WinZip, 2. then select Extract to here... This action will place a new folder called "Care Transitions Toolkit" where you have chosen to save the file.)

•   Care Transitions Toolkit

NEW - Top Ten Facts Physicians Need to Know About Coaches 

NEW - Resources for 9.24.09 QIOSC Care Transitions Learning Session - Pennsylvania Care Transitions Coaching: Our Journey

• Download the Learning Session Recording
• Agenda and Materials List
• Agreement to Participate Form
• Coach Criteria Checklist
• Coach Workflow
• Patient Coaching Flyer
• Physician Coaching Flyer
• Personal Health Record
• Top Ten Facts of Coaching Poster
• What's Up Doc Letter

Web sites

Additional resources involving Care Transitions:

• Colorado Foundation for Medical Care
• The Care Transitions Program ^SM
• MedQIC - Care Transitions
• Project RED
• Project BOOST
• TMF Health Quality Institute Care Transitions Program
   

Newsletter

Back issues of the Transitions Insights newsletter are available in the Newsletter Archive.

NEW - Home Care Outcomes, April 2009 
Article about the Care Transitions project. 
For more information on the Home Care Outcomes newsletter, please visit www.decisionhealth.com, or call 1-877-602-3835.


Media Resources

1. Partnering with the Continuum of Care to Create a Person-Centered Experience by Heidi Gil, Continuing Care Director, Planetree - 10.22.09
   This recorded learning session and handouts focus on the experience of Planetree in building a patient centered continuum of care that integrates the critical components necessary to improve the quality of transitions of care across this continuum.
   Download Handout 1
   Download Handout 2
   Listen to the Audio
    
2. Care Transitions Performance Measures: Promoting Better Inpatient and Emergency Department Discharges by Mark Antman, DDS, MBA Senior Policy Analyst III, Clinical Performance Evaluation, American Medical Association - 09.10.09
   This call and handouts are aimed to provide you with an overview of the work done by the ABIM Foundation, American College of Physicians, Society of Hospital Medicine, and Physician Consortium for Performance Improvement (PCPI). They jointly formed a Care Transitions Work Group (CTWG) to identify and define quality measures toward improving outcomes for patients undergoing transitions in care.
   Download Handout 1
   Download Handout 2
   Listen to the Audio
    
3. Collaboration with AAAs and ADRCs by Lori A. Gerhard, CASP, NHA - 6.12.08
   This recorded call and handouts focus on the Area Agency on Aging (AAA) and Aging and Disability Resource Centers (ADRC). Lori A. Gerhard, CASP, NHA outlines the resources of the AAA and ADRC and the potential collaboration between them and the QIO's in Care Transitions.
   Download the Handouts
   Listen to the Audio
    
4. CARE (Continuity Assessment Record and Evaluation) Overview by Judith Tobin, PT, MBA - 5.15.08
   This recorded call/handouts focuses on the CARE (Continuity Assessment Record and Evaluation) Tool.  Judith Tobin outlines the background of CARE, the PAC (Post Acute Care) Payment Demo, and the importance to CMS of developing a standardized assessment instrument. 
   Download the Handouts
   Listen to the Audio 
    
5. Improving Nursing Home Care by Reducing Avoidable Hopsitalizations by Joseph G. Ouslander - 3.06.08
   This recorded call and handouts focus on Improving Nursing Home Care by Reducing Avoidable Acute Care Transfers and Hospitalizations. Joseph G. Ouslander, M.D. walks through a pilot study on nursing home rehospitalizations and highlights the findings, conclusions, and next steps towards reducing acute care rehospitalizations.
   Download the Handout 1
   Download the Handout 2
   Listen to the Audio
    
6. Care Transitions Interventions by Eric Coleman, MD - 12.20.07
   This recorded call/handouts focuses on the Care Transition Intervention featuring the challenges and opportunities for improving quality and safety during care transitions and the elements of the CTI that may help overcome challenges.
   Download the Handouts
   Listen to the Audio