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Transitional Care/After Care

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  • Topic: Transitional care/after care
  • Topic: Patient safety and outcomes
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When Getting There Isn't Half the Fun

September 1, 2003 | Program Result Report

The University of Colorado Health Sciences Center hosted a conference to develop research and policy agendas for improving the quality of care for persons who are transferred from one medical setting to another.

Quality and Cost Analysis of Nurse Staffing, Discharge Preparation, and Postdischarge Utilization

April 21, 2011 | Journal Article

Investments in nursing care hours reduce hospital readmissions by better preparing patients for discharge.

Nurse Identified Hospital to Home Medication Discrepancies

May 1, 2010 | Journal Article

In this study, nurse interventionists identified and documented medication discrepancies from two Inland Northwest hospitals. The researchers identified more system-level discrepancies than patient-level ones.

Section 5: How-To Guides

February 4, 2009 | Toolkit

How-to guides supported through TCAB, a national program of RWJF and the Institute for Healthcare Improvement, offer detailed steps to implement select aspects of the program.

Heart Failure Encounter Form

June 1, 2008 | Toolkit

An off-site, nurse-led heart failure clinic was created to help heart failure patients better control and self-manage their disease post-hospitalization.

Cardiology Admission Orders Physician's Order Sheet

June 4, 2008 | Toolkit

Staff combined information from three existing order sets into a single, comprehensive cardiology admission order set to reduce provider confusion and help the hospital reach regular compliance rates of 90 to 100% for evidence-based cardiac measures.

Measuring Healthcare Outcomes to Improve Quality of Care Across Post-Acute Care Provider Settings

October 1, 2004 | Journal Article

Post-acute care (PAC) is being provided more frequently across a number of settings including skilled nursing facilities (SNFs), rehabilitation facilities (RFs) and home health agencies (HHAs).

Increased Access to Medicaid Had Little Effect on Pregnancy Care or Outcome

January 1, 2001 | Program Result Report

From 1991 to 1996, investigators at Harvard Medical School examined the effects of Medicaid eligibility expansions on a range of maternal and neonatal outcomes in California and South Carolina.

Discharge Nurse Position Description

June 4, 2008 | Toolkit

Staff at the University of Texas M.D. Anderson Cancer Center, Houston, Texas, began using an experienced nurse to support the clinical nurses by coordinating discharge activities, serving as a liaison to other team members and ensuring that all aspects of discharge are complete for patients and families.

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