Care Transitions: Information for Patients and Community
Older patients with chronic illnesses often need care from various doctors, nurses and other medical professionals. Older patients also receive care from many places, including hospitals, nursing homes, home health agencies and doctors’ offices.
As patients move between settings, or transition between settings, it’s important to share information with all the people who care for this patient. It’s also important that patients understand their illnesses and how those illnesses are being treated.
The goal of the Care Transitions project is to help patients and their caregivers actively participate in their transitions. This will help patients get better and feel better about their care. There are two steps in meeting this goal: first, patients should better understand how their illness is being taken care of, and second, patients should know more about transitions.
Together, we can meet these goals by giving patients and their caregivers helpful information and teaching them about their illnesses and their care between and after transitions.
Community Assessment Toolkit Now Online
The ATW Community Assessment Toolkit provides communities a process to determine the current capacity of their community to serve a growing aging population and to undertake planning and action to build an aging-friendly community. The Toolkit is now available for self-directed use by communities to begin their assessment process. However, DADS technical assistance will not be available until field testing of the instrument is complete in 2010.
How to Keep Track of Your Care: The Personal Health Record
This English/Spanish Personal Health Record and Medication Record can help you keep track of your health care. Use a pencil to write down all the details of your care and medications, and update this form when something changes. Make sure you share these forms with your doctors, nurses and pharmacists.
Remember, this is your form to keep. Share the information with your health care team, but ask them to return it after they’ve found the information they need.
Helpful tips: Print these pages on brightly colored paper to help you locate them easily.
- Personal Health Record/Registro Personal de la Salud (4 sheets, PDF)
Download and print this small booklet to record your health care history and medicines. Click on the title above, and then follow the instructions in the boxes that appear on your computer screen.
Instructions for assembly: First, pair the sheet printed with pages 8 and 1 with the sheet printed with pages 2 and 7. Place them together so the printed sides of each sheet face outward. Then fold these two sheets in half to create the “spine” of your booklet. Pages 1 and 8 will be the front and back cover of your booklet, and pages 2 and 7 will form the inside pages. Then pair the remaining two sheets together like the first set. Again, the printed sides of each sheet should face outward. Fold them in half vertically so pages 3 and 6 face outward. Finally, open the first set of pages, and place the second set on top. Fold them together to create your booklet. Check the page numbers to make sure the sheets are folded in the correct order.
- Medication Record/Registro de Medicinas (2 sheets, PDF)
It’s very important to have up-to-date information about your medicines for your health care team. Use this form to list every medicine you take, even aspirin, vitamins and herbal remedies. If you need more room to list everything, add an extra Medication Record sheet.
Instructions for assembly: Place the sheets together with the printed sides facing outward. Fold the two sheets in half to create the spine.
- Extra Medication Record sheets (1-page PDF)
If you need more space to list your medicines, download and print this page. Keep it with your Medication Record.
When You Leave the Hospital: Discharge Preparation Checklists
When patients come home from the hospital or go to a nursing home, doctors often have lots of instructions. We've provided two versions of a discharge checklist for patients to use before leaving the hospital.
This Discharge Preparation Checklist keeps track of those instructions as well as reminds patients to ask important questions that will make transitions easier.
The Centers for Medicare & Medicaid Services has prepared this discharge checklist for patients leaving hospitals, nursing homes or other care settings. It also includes contact information for helpful organizations and agencies.
End of Life Planning
Talking About End-of-Life Treatment Decisions
Agency for Healthcare Research and Quality Director Carolyn M. Clancy, MD, offers patients and their families guidance on end-of-life planning and discusses how having these plans in place can alleviate fear and anxiety for patients and their families.
American Bar Association's Commission on Law & Aging
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.
Aging with Dignity: Five Wishes
Five Wishes has become America’s most popular living will because it is written in everyday language and helps start and structure important conversations about care in times of serious illness.
Spanish-language Five Wishes [20-page PDF, 380kb]
AARP: Advance Directives: Planning for the Future
This section of the AARP site provides dozens of helpful tools and resources to help guide your end-of-life planning, including developing your advance directives.
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.
National Long Term Care Ombudsman Resource Center: Helpful Contacts
An Ombudsman is an advocate for residents of nursing homes, board and care homes, and assisted living. Ombudsmen provide information about how to find a facility and what to do to get quality care. They are trained to resolve problems.
Other Helpful Information for Patients and Their Caregivers
Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient
Use materials from this toolkit to help you or your loved one move safely from the hospital to home or to your next care setting.
Resources for End of Life Issues
This comprehensive resource page is sponsored by the U.S. National Library of Medicine and the National Institutes of Health. Patients or caregivers faced with planning end-of-life of care will find the links useful in locating assistance and learning more about options available to them.
Questions Are the Answer: Get More Involved in Your Health Care
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.
Get Health Information in Your Native Language
MedlinePlus 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 Next Step in Care: Get Helpful Information About Transitions in Care
This site helps patients and families with the keys to smooth transitions: careful planning, clear communication and ongoing coordination.
New Web Tool Helps You Choose a Nursing Home
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 discusses a new Web tool that helps you compare your nursing home choices.
20 Tips to Help Prevent Medical Errors (4pp PDF, 223kb)
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.
Be Prepared for Medical Appointments Brochure (2pp PDF, 100kb)
Successfully prepare for doctor’s visits with this easy-to-read, two-page brochure that outlines questions to ask and simple steps to take.
Care Transitions in the News
Brownsville Herald: Agency uses Valley as test site for new program
If successful, this program could change the health care landscape in the Valley.
The Monitor: Rio Grande Valley to be part of study to cut hospital re-admissions
The federal agency that oversees Medicare has chosen the Rio Grande Valley as one of 14 sites to test a nationwide program that would cut down on re-admissions to the hospital and improve patients' health.
Valley Morning Star: Valley chosen to test health care program
Of the approximately 13,000 Medicare patients hospitalized each year in the Brownsville, Harlingen and Weslaco areas, about one-fourth return to the hospital within 30 days.
La Feria News: Valley Hospitals Embrace New System, Knapp Medical Center Hosts Seminar
Health care providers in the Valley rally around program to reduce avoidable hospitalizations and help patients stay healthy and at home.