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Care Transitions is a communitywide project focusing on improving patients’ transitions across care settings to reduce avoidable hospitalizations.
March 11, 2010
You are here: What's New

Newly Posted to Care Transitions Project Web site

What's NewThe following tools and resources have been posted to this Web site within the three months. They have also been posted under the topic/provider sections that they support. Please check here periodically for newly posted resources and tools.

Hospitals and Inpatient Rehabs

Downloads from the Brownsville Conference on January 21, 2010, “18-Month Care Transitions Project Update: Care Transitions Measurement Is Here: Are You Ready?”
This Conference to re-energize the Care Transitions Project at the beginning of the final measurement period brought several nationally acclaimed speakers to the Valley. Learn new ins and outs for transitioning patients. 02-12-10

Patient Self-Care Workbooks for COPD, Diabetes and Heart Failure
These three Patient Self-Care Workbooks may be used by clinicians to help educate patients(or caregivers) about chronic obstructive pulmonary disease (COPD), diabetes and heart failure. They provide simple explanations of each of the diseases and cover signs and symptoms to report to your physician, medications, diet and exercise considerations, and treatment information. The workbooks encourage patients to become involved in the management of their own chronic illnesses by helping them set goals and recommending an easy way for them to document their progress. 
Note: The booklets are several pages long and may take a few moments to download. You can dowload the entire workbook (4.57kbs ZIP) or each individually below. 01-27-10  

Follow-up Appointment Card and Instructions for Hospital Discharge Professionals 
(English, 482kbs PDF)/Spanish (431kbs PDF)
The purpose of these cards is to help discharge health care professionals schedule follow-up visits with physicians for patients being discharged. The patient checks the day (or days) of the week and the time of day (morning or afternoon) when he or she can visit a doctor. The person discharging the patient then makes the appointments and writes the appointments down on the card on a day and at a time that the patient has checked. The patient then takes this follow-up appointment card home. 03-10-10  

Worksheet for Testing Change
This is a tool to help you implement the Plan-Do-Study-Act (PDSA) process improvement method. “Plan” – The organization digs deep to determine the root causes that triggered the need for improvement. “Do” – the plan is put into action. “Study” – How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act” – Integrate successful plans into organizational processes. 12-17-09

Re-engineering Discharge (RED) Patient Survey
English  (315 kbs PDF) Spanish (271 kbs PDF)
This patient survey tool is to be used to collect RED monitoring data in conjunction with the Excel RED Data Monitoring Collection Tool. 12-09-09

Hospital to Home national quality initiative

The Hospital to Home (H2H) national quality initiative, cosponsored by the American College of Cardiology and the Institute for Healthcare Improvement, 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 to join a community of health care providers that are committed to improving care. 12-08-09

Teach-Back Practice and CHF Medications Tool (544kbs PDF)
Nurses in hospitals, nursing homes, home health agencies and physician offices will find this tool useful for teaching Congestive Heart Failure (CHF) patients about their medications. Included are a cover reminder card, nine medication cards, three core measure (AMI, CHF and Pneumonia) cards and a card listing ACE-inhibitors and beta blockers. Each medication card includes: 1) How the class of drug works, 2) What problems to report to the doctor/nurse, and 3) The brand or generic drug names by class. 12-07-09

Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words. You say, “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” The deck of cards is easy to print and use. By employing it, you promote both health literacy and patient safety. 12-03-09

TMF Care Transitions “After Care Plan and Zone Tools” Package (Zip package)
The purpose of this package of tools is two-fold: first, the completed documents will give your patients the information and tools they need to better manage their health at home or in the next care setting. Second, it is a uniform resource for each health care provider to access and update as needed.
The package includes a User’s Guide, Discharge Checklists (in English and Spanish), the customizable After Care Plan (English and English/Spanish versions), additional calendar templates and the following zone self-management tools (click to download individually as needed):

Skilled Nursing Facilities

Downloads from the Brownsville Conference on January 21, 2010, “18-Month Care Transitions Project Update: Care Transitions Measurement Is Here: Are You Ready?”
This Conference to re-energize the Care Transitions Project at the beginning of the final measurement period brought several nationally acclaimed speakers to the Valley. Learn new ins and outs for transitioning patients. 02-12-10

Patient Self-Care Workbooks for COPD, Diabetes and Heart Failure
These three Patient Self-Care Workbooks may be used by clinicians to help educate patients(or caregivers) about chronic obstructive pulmonary disease (COPD), diabetes and heart failure. They provide simple explanations of each of the diseases and cover signs and symptoms to report to your physician, medications, diet and exercise considerations, and treatment information. The workbooks encourage patients to become involved in the management of their own chronic illnesses by helping them set goals and recommending an easy way for them to document their progress.
Note: The booklets are several pages long and may take a few moments to download. You can dowload the entire workbook (4.57kbs ZIP) or each individually below. 01-27-10  

Worksheet for Testing Change
This is a tool to help you implement the Plan-Do-Study-Act (PDSA) process improvement method. “Plan” – The organization digs deep to determine the root causes that triggered the need for improvement. “Do” – the plan is put into action. “Study” – How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act” – Integrate successful plans into organizational processes. 12-17-09

Teach-Back Practice and CHF Medications Tool (544kbs PDF)
Nurses in hospitals, nursing homes, home health agencies and physician offices will find this tool useful for teaching Congestive Heart Failure (CHF) patients about their medications. Included are a cover reminder card, nine medication cards, three core measure (AMI, CHF and Pneumonia) cards and a card listing ACE-inhibitors and beta blockers. Each medication card includes: 1) How the class of drug works, 2) What problems to report to the doctor/nurse, and 3) The brand or generic drug names by class.

Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words. You say, “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” The deck of cards is easy to print and use. By employing it, you promote both health literacy and patient safety. 12-03-09

INTERACT II programThe INTERACT II Program is designed to improve the quality of nursing home care by providing tools and resources to staff that will help to Reduce Avoidable Acute Care Transfers.

The first version of the INTERACT program was developed by the Georgia Medical Care Foundation, the Medicare Quality Improvement Organization for the state of Georgia, with the support of a contract from the Center for Medicare and Medicaid Services. The development of INTERACT II has been supported through a generous grant from The Commonwealth Fund.

Newly revised INTERACT II tools can help reduce avoidable acute care transfers. Use them for early identification of a change in resident status, to guide you or nursing home staff through a comprehensive resident assessment when a change is noted, for improving documentation and enhancing communication.

TMF Care Transitions “After Care Plan and Zone Tools” Package (Zip package)
The purpose of this package of tools is two-fold: first, the completed documents will give your patients the information and tools they need to better manage their health at home or in the next care setting. Second, it is a uniform resource for each health care provider to access and update as needed.
The package includes a User’s Guide, Discharge Checklists (in English and Spanish), the customizable After Care Plan (English and English/Spanish versions), additional calendar templates and the following zone self-management tools (click to download individually as needed):

Clinics & Physicians

Patient Self-Care Workbooks for COPD, Diabetes and Heart Failure
These three Patient Self-Care Workbooks may be used by clinicians to help educate patients(or caregivers) about chronic obstructive pulmonary disease (COPD), diabetes and heart failure. They provide simple explanations of each of the diseases and cover risk factors, medications, diet and exercise considerations, and treatment information. The workbooks encourage patients to become involved in the management of their own chronic illnesses by helping them set goals and recommending an easy way for them to document their progress.
Note: The booklets are several pages long and may take a few moments to download. You can dowload the entire workbook (4.57kbs ZIP) or each individually below. 01-27-10  

Teach-Back Practice and CHF Medications Tool (544kbs PDF)
Nurses in hospitals, nursing homes, home health agencies and physician offices will find this tool useful for teaching Congestive Heart Failure (CHF) patients about their medications. Included are a cover reminder card, nine medication cards, three core measure (AMI, CHF and Pneumonia) cards and a card listing ACE-inhibitors and beta blockers. Each medication card includes: 1) How the class of drug works, 2) What problems to report to the doctor/nurse, and 3) The brand or generic drug names by class.

Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words. You say, “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” The deck of cards is easy to print and use. By employing it, you promote both health literacy and patient safety. 12-03-09 

Home Health Agencies

 

Downloads from the Brownsville Conference on January 21, 2010, “18-Month Care Transitions Project Update: Care Transitions Measurement Is Here: Are You Ready?”
This Conference to re-energize the Care Transitions Project at the beginning of the final measurement period brought several nationally acclaimed speakers to the Valley. Learn new ins and outs for transitioning patients. 02-12-10

Patient Self-Care Workbooks for COPD, Diabetes and Heart Failure
These three Patient Self-Care Workbooks may be used by clinicians to help educate patients(or caregivers) about chronic obstructive pulmonary disease (COPD), diabetes and heart failure. They provide simple explanations of each of the diseases and cover signs and symptoms to report to your physician, medications, diet and exercise considerations, and treatment information. The workbooks encourage patients to become involved in the management of their own chronic illnesses by helping them set goals and recommending an easy way for them to document their progress. 
Note: The booklets are several pages long and may take a few moments to download. You can dowload the entire workbook (4.57kbs ZIP) or each individually below. 01-27-10  

COPD Patient Self-Care Workbook
English Printer Spread (booklet, 732kbs PDF), English Reader Spread (individual pages, 720kbs PDF )
Spanish Printer Spread (booklet, 734kbs PDF), Spanish Reader Spread (individual pages, 725kbs PDF)

Diabetes Patient Self-Care Workbook
English Printer Spread (booklet, 626kbs PDF), English Reader Spread (individual pages, 605kbs PDF)
Spanish Printer Spread (booklet, 640kbs PDF), Spanish Reader Spread (individual pages, 620kbs PDF)

Heart Failure Self-Care Workbook
English Printer Spread (booklet, 782kbs PDF),English Reader Spread (individual pages, 772kbs PDF)
Spanish Printer Spread (booklet, 775kbs PDF), Spanish Reader Spread (individual pages, 765kbs PDF)

Worksheet for Testing Change
This is a tool to help you implement the Plan-Do-Study-Act (PDSA) process improvement method. “Plan” – The organization digs deep to determine the root causes that triggered the need for improvement. “Do” – the plan is put into action. “Study” – How well did the plan work? If it worked well, proceed to “act.” If not, go back to “plan” and start over. “Act” – Integrate successful plans into organizational processes. 12-17-09

Teach-Back Practice and CHF Medications Tool (544kbs PDF)
Nurses in hospitals, nursing homes, home health agencies and physician offices will find this tool useful for teaching Congestive Heart Failure (CHF) patients about their medications. Included are a cover reminder card, nine medication cards, three core measure (AMI, CHF and Pneumonia) cards and a card listing ACE-inhibitors and beta blockers. Each medication card includes: 1) How the class of drug works, 2) What problems to report to the doctor/nurse, and 3) The brand or generic drug names by class.

Patients are asked, in a shame-free environment, to simply repeat back what you have taught them in their own words. You say, “I want to make sure I explained this clearly. When you get back home in a few days, what will you tell your [friend or family member] about [key point just discussed]?” The deck of cards is easy to print and use. By employing it, you promote both health literacy and patient safety. 12-03-09

Patients and Community

Patient Self-Care Workbooks for COPD, Diabetes and Heart Failure
These three Patient Self-Care Workbooks may be used by clinicians to help educate patients(or caregivers) about chronic obstructive pulmonary disease (COPD), diabetes and heart failure. They provide simple explanations of each of the diseases and cover signs and symptoms to report to your physician, medications, diet and exercise considerations, and treatment information. The workbooks encourage patients to become involved in the management of their own chronic illnesses by helping them set goals and recommending an easy way for them to document their progress.
Note: The booklets are several pages long and may take a few moments to download. You can dowload the entire workbook (4.57kbs ZIP) or each individually below. 01-27-10  

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. 11-11-09

Recorded Events

Insights About the Challenges of the Revolving Door of the Hospital
Insights About the Challenges of the Revolving Door of the Hospital, presented by Harlan Krumholz, MD, Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health at Yale University School of Medicine.  This presentation was recorded live at our January 21, 2010 Conference in Brownsville, TX. Dr. Krumholz discusses the Hospital to Home Initiative, a collaborative effort with the Institute of Healthcare Improvement (IHI) and the American College of Cardiology (ACC), utilizing heart failure guidelines to standardize care and improve outcomes. 02-04-09

TMF has received Independent Review Organization accreditation from URAC. TMF has received Health Utilization Management accreditation from URAC. TMF is a GSA Contract Holder.