Care Transitions Case Review Home Health Hospitals Kidney Health Nursing Homes Part D Drug Safety People with Medicare Physicians TMF Services TMF.org

•  Care Transitions Home http://caretransitions.tmf.org/CareTransitionsHome/tabid/778/Default.aspx Care Transitions is a project through the Centers for Medicare & Medicaid Services. Its goal is to reduce the rate of avoidable rehospitalization by improving patients’ transitions across care settings. •  Timeline http://caretransitions.tmf.org/Timeline/tabid/887/Default.aspx •  Patients & Community http://caretransitions.tmf.org/PatientsCommunity/tabid/830/Default.aspx TMF Care Transitions: Information for Patients and Their Communities •  Care Transitions Intervention http://caretransitions.tmf.org/CareTransitionsIntervention/tabid/1027/Default.aspx The Care Transition Intervention aids in the adoption and implementation of policies and tactics that will improve how patients move among care settings. •  Provider Interventions & Tools http://caretransitions.tmf.org/ProviderInterventionsTools/tabid/831/Default.aspx Downloadable tools and materials to support improved care transitions            •  Clinics/Physician             http://caretransitions.tmf.org/ProviderInterventionsTools/ClinicsPhysician/tabid/1013/Default.aspx             Care Transition intervention strategies for clinics and physicians.            •  Home Health Agencies & Hospices             http://caretransitions.tmf.org/ProviderInterventionsTools/HomeHealthAgenciesHospices/tabid/832/Default.aspx             National Campaign Interventions and tools for home health and hospices to improve Care Transitions.            •  Hospitals and Inpatient Rehabs             http://caretransitions.tmf.org/ProviderInterventionsTools/HospitalsandInpatientRehabs/tabid/833/Default.aspx             Care Transition intervention strategies for hospitals and inpatient rehab facilities.            •  Skilled Nursing Facilities             http://caretransitions.tmf.org/ProviderInterventionsTools/SkilledNursingFacilities/tabid/835/Default.aspx             Interventions and tools on the Care Transitions project for participating skilled nursing facilities •  Provider Reporting & Intervention http://caretransitions.tmf.org/ProviderReportingIntervention/tabid/1017/Default.aspx Submit your provider monthly reports.            •  Home Health Agencies & Hospices             http://caretransitions.tmf.org/ProviderReportingIntervention/HomeHealthAgenciesHospices/tabid/1018/Default.aspx             Home health monthly reporting form and interventions.            •  Hospital and Inpatient Rehabs             http://caretransitions.tmf.org/ProviderReportingIntervention/HospitalandInpatientRehabs/tabid/1019/Default.aspx             Hospital and inpatient rehabs monthly reporting form and interventions.            •  Skilled Nursing Facilities             http://caretransitions.tmf.org/ProviderReportingIntervention/SkilledNursingFacilities/tabid/1020/Default.aspx             Skilled nursing facilitites monthly reporting form and interventions. •  Improvement Tracker http://caretransitions.tmf.org/ImprovementTracker/tabid/914/Default.aspx Providers are encouraged to use this tracking tool from the Institute of Healthcare Improvement to set metrics on their interventions. •  Research & References http://caretransitions.tmf.org/ResearchReferences/tabid/837/Default.aspx Research and references supporting interventions that improve care transitions            •  Research             http://caretransitions.tmf.org/ResearchReferences/Research/tabid/886/Default.aspx             Research supporting the TMF Care Transitions project in the Lower Rio Grande Valley.            •  References             http://caretransitions.tmf.org/ResearchReferences/References/tabid/907/Default.aspx             Reference information supporting the TMF Care Transitions project in the Lower Rio Grande Valley. •  The Business Case http://caretransitions.tmf.org/TheBusinessCase/tabid/945/Default.aspx The business case for care transitions. •  Chronic Care Model http://caretransitions.tmf.org/ChronicCareModel/tabid/836/Default.aspx Chronic Care Model information that supports improved care transitions •  What's New http://caretransitions.tmf.org/WhatsNew/tabid/1047/Default.aspx Newly posted resources and tools to the care transitions Web site. •  Events http://caretransitions.tmf.org/Events/tabid/839/Default.aspx Events and community meetings related to the Texas Care Transitions project            •  Upcoming Events             http://caretransitions.tmf.org/Events/UpcomingEvents/tabid/847/Default.aspx             Upcoming Events            •  Recorded Events             http://caretransitions.tmf.org/Events/RecordedEvents/tabid/848/Default.aspx             Recorded Events •  Links http://caretransitions.tmf.org/Links/tabid/838/Default.aspx Online resources and links to information regarding Care Transitions •  Care Transitions E-Newsletter http://caretransitions.tmf.org/CareTransitionsENewsletter/tabid/935/Default.aspx •  Calendar of Activities http://caretransitions.tmf.org/CalendarofActivities/tabid/885/Default.aspx Events and community meetings related to the Texas Care Transitions project •  Part D Drug Safety http://caretransitions.tmf.orghttp://partddrugsafety.tmf.org Quality improvement project that targets adverse drug events in the elderly •  Web Site Feedback http://caretransitions.tmf.org/WebSiteFeedback/tabid/934/Default.aspx •  Contact Us http://caretransitions.tmf.org/ContactUs/tabid/844/Default.aspx Contact information for the TMF Care Transitions team. •  Participation Agreement http://caretransitions.tmf.org/ParticipationAgreement/tabid/800/Default.aspx The online participation agreement for the Texas Care Transitions project. •  Helper Files http://caretransitions.tmf.org/HelperFiles/tabid/882/Default.aspx Help with files and plug-ins