Best Practices and Guides

Best Practice Intervention Packages

The Home Health Quality Improvement National Campaign (2008).

This campaign has tracks for various roles and professionals:  leadership, nurses, therapists, social workers, and home health aides.  After completion of each package, the learner is able to describe transitional care coordination and the role of home health; recognizes partnership of patient and caregiver in reduction of acute care hospitalization; and understands the clinical practices that promote effective care transitions.

  • Full Contents

    This document contains all five tracks (leadership, nurse, therapist, medical social worker, and home health aide).

  • Fast Track
    This document provides a quick overview of transitional care coordination and discusses the four pillars of care transitions.
Interact II

INTERACT is an acronym for “Interventions to Reduce Acute Care Transfers”.  It is a quality improvement program designed to reduce transfers from nursing homes to hospitals.

Transition Guides

Improving Transitions of Care: Hospital to Home
National Transitions of Care Coalition, 2009

This 78-page document is a comprehensive guide toward evaluating and improving care transitions at an institution. The appendices include topics including hospital receipt of patients, literature review for transitions from hospital to home, and care transition intervention programs.

Improving Transitions of Care: Emergency Department to Home
National Transitions of Care Coalition, 2009

This 68 page document discusses care transitions from the emergency department (ED) to home. The guide provides direction to assess the current process and level of performance, talks about determining intervention strategy and its implementation. The appendices include topics such as patient or family caregiver takes over care coordination, literature review for transition from ED to home and quality indicators for geriatric emergency care.

Transport of Non-ICU patients
Patient Safety Authority, 3/2009

This article describes issues related to safe intra-hospital transport of non-ICU patients.