Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

Transition Care Support - Tools and Resources

Gap Analysis

Effective transition care support is dependent on structures and processes. Implementing or enhancing a transition care support program should start with a gap analysis to examine how your organization is currently performing. The gap analysis provides insight into the needs for improvement. Transition Care Support Gap Analysis (1-page Word doc)

Tools and Resources

Frequently Asked Questions: Transitional Care Management. FAQ from the American Academy of Family Physicians (AAFP) regarding the two CPT codes added to report transitional care management (TCM), effective January 1, 2013.

Patient/Family Materials

Getting Ready to Go Home. Patient/Family Discharge Planning Checklist. This tool provides patients and family members with a list of questions that they should have answered and information on prior to discharge.

Next Step in Care. Supported by the United Hospital Fund, this website includes a variety of provider and caregiver resources and checklists. Patient/family materials are available in English, Spanish, Russian, and Chinese.

Patient PASS: A Transition Record. Developed as part of the Society of Hospital Medicine's Project BOOST (Better Outcomes for Older adults through Safe Transitions). (1-page PDF)

Personal Health Record - Discharge Preparation Checklist. Patient health record information including a structured checklist of critical activities a patient must be able to do to manage their care. (6-page PDF)

Your Discharge Planning Checklist. CMS developed a checklist that prompts patients and caregivers to ask questions about key discharge planning topics including their likely care needs, the options for continuing care, post-discharge care instructions, community-based resources, and more. (6-page PDF)


Better Outcomes for Older Adults through Safe Transitions (BOOST). Toolkit for improving hospital discharge, including screening/assessment tools, discharge checklist, transition record, teach-back process, risk-specific Interventions, and written discharge instructions.

Care CoPILOT - Care Guide Model. This patient-centered care delivery model uses a care guide who is a non-clinically trained layperson having a collaborative role within a team-based clinical setting; and tasked with building longitudinal relationships with patients to help achieve evidence-based care goals. It focuses on prevention, wellness and chronic disease management.

The Bridge Model. Social work based transitional care model designed for older adults discharged home from an inpatient hospital stay. Bridge helps older adults to safely transition back to the community through intensive care coordination that starts in the hospital and continues after discharge to the community.

Care Transitions Program. Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure that patient's needs are met during the transition from the acute care setting to home.

  • The Care Transitions Intervention. Eric Coleman, MD, director of the care transitions program at the University of Colorado in Denver, explains how to improve transitional care through engagement at the patient, provider, and health care institution levels. For each of these multiple levels, promising new innovations are featured. These include a transition specific self-care model that has been adopted by leading health care systems, new tools for detecting medication problems that arise during care transitions, and state-of-the-art performance measurement tools. The presentation concludes with a discussion of important developments in transitional care policy at the national level. (Recorded June 8, 2011) Part 1 (26-minute podcast), Part 2 (25-minute podcast)

Project RED (Re-engineered Discharge). Standardized discharge intervention; includes patient education comprehensive discharge planning and post-discharge telephone reinforcement. Developed by the Boston University Medical Center.

Transitional Care Model. This model provides comprehensive in-hospital planning and home follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. Transitional care nurses follow patients from the hospital into the home to provide services.

Success Stories

HealthEast Care Navigation Strategy. Rahul Koranne, MD, MBA, FACP, medical director, HealthEast Care System of St. Paul, describes HealthEast's Care Navigation Strategy including its components, how it was developed and the outcomes it has achieved. (Recorded February 17, 2011) Part 1 (25-minute podcast), Part 2 (26-minute podcast)  Handout (32-page PDF)


IHI How-to-Guide: Improving Transitions from the Hospital to Post-Acute Care Settings to Reduce Avoidable Rehospitalizations. Rutherford P, Nielsen GA, Taylor J, Bradke P, Coleman E. Cambridge, MA. Institute for Healthcare Improvement, June 2011.

IHI How-to-Guide: Improving Transitions from the Hospital to the Clinical Office Practice to Reduce Avoidable Rehospitalizations. Schall M, Coleman E, Rutherford P, Taylor J. Cambridge, MA. Institute for Healthcare Improvement, June 2011.

IHI How-to-Guide: Improving Transitions from the Hospital to Skilled Nursing Facilities to Reduce Avoidable Rehospitalizations. Herndon L, Bones C, Kurapati S, Rutherford P, Vecchioni N. MA: Institute for Healthcare Improvement, June 2011.

IHI: How-to-Guide: Improving Transitions from the Hospital to Home Health Care to Reduce Avoidable Rehospitalizations. Taylor J, Sevin C, Rutherford P, Coleman EA. Cambridge, MA: Institute for Healthcare Improvement, June 2011.

The Post-Hospital Follow-Up Visit: A Physician Checklist to Reduce Readmissions. The post-hospital follow-up visit presents a critical opportunity to address the conditions that precipitated hospitalization and to prepare the patient and family caregiver for self-care activities. The purpose of this evolving document is to foster physician engagement regarding roles and accountability for patients transitioning from the hospital back to the ambulatory arena. (9-page PDF)

There and Home Again, Safely. 5 Responsibilities of Ambulatory Practices in High Quality Care Transitions. The American Medical Association (AMA) has released five patient safety principles for transitioning patients from inpatient to outpatient care. Evaluating patient heath, supporting self-management and medication management, as well as goal setting were among the responsibilities outlined in the report. (77-page PDF)

Key Literature

The Care Transitions Intervention: results of a randomized controlled trial. Coleman EA, Parry, Chalmers S. Min SJ. Arch Internal Medicine. 2006; 166(17): 1822-1828.

Early surgical follow-up with primary care physicians can cut hospital readmission. Patients who have post-operative complications following high-risk surgery have a significantly lower risk of being readmitted to the hospital within 30 days if they go see their primary care physician soon following discharge, a new study in JAMA Surgery shows. Medical Xpress.

Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Preen DB, Bailey BE, Wright A, Kendall P, Phillips M, Hung J, Hendriks R, Mather A, Williams E. International Journal for Quality in Health Care. 2005 Feb;17(1):43-51.

The impact of postdischarge telephonic follow-up on hospital readmissions. Harrison PL, Hara PA, Pope JE, Young MC, Rula EY. Population Health Management. 2011 Feb;14(1):27-32. Epub 2010 Nov 19.

A Reegineered hospital discharge program to decrease rehospitalization: a randomized trial. Jack BW, Chetty Vk, Anthony D, et al. Annals of Internal Medicine. 2009; 150(3): 178-187.

Rehospitalizations among patients in the medicare fee-for-service program. Jenc ks SF, Williams MV, Coleman EA. The New England Journal of Medicine. 2009; Volume 360:1418-28.

Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. Naylor MD, Brooten DA, Campbell RL, Maislin G, McCauley KM, Schwrtz JS. Journal of the American Geriatrics Society. 2004:52(5): 675-684

Patients and family members
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