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Transition Communications - Tools and Resources

Gap Analysis

Safe transitions are dependent on structures and processes which have been identified as the safe components and actions. Implementation of the safe transitions 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 toward safe transitions of care. Safe Transitions Gap Analysis (3-page PDF)

Tools and Resources

Safe Transitions of Care Toolkit. This toolkit developed by the Minnesota Hospital Association contains resources on:

  • Safe Transitions of Care template form
  • Safe Transition of Care core element crosswalk
  • Sample transition/discharge checklists
  • Sample policies
  • Staff education
  • Patient education and resources
  • Audit tools

Sample Policies

Discharge Planning and Referral. Example from Olmsted Medical Center. (4-page Word doc)

Discharge Transfer Care Planning Process and Implementation. Example from HealthEast Hospitals. (5-page PDF)

Hard Stop Policy. Example from Olmsted Medical Center. (1-page PDF)

Model Transfer Policy. Guidance from the Minnesota Hospital Association on considerations for organizational policy development. (9-page Word doc)


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 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)

Safe Transitions of Care Pilot by the Minnesota Hospital Association. Building on hospitals' ongoing work to reduce readmissions, MHA focused on improving patient safety by standardizing core elements of information during transitions of care between hospitals and across settings. MHA identified patient safety gaps due to transitions of care and core elements of information to close these gaps. Thirteen hospitals participated in MHA's pilot to incorporate the core elements into the discharge process. This webinar shares the lessons learned from the MHA safe transition pilot. (Recorded May 25, 2011) Part 1 (21-minute podcast), Part 2 (23-minute podcast) Handout (35-page PDF)

Targeted Solutions Tool for Hand-off Communications. Ten leading health care organizations, together with the Joint Commission Center for Transforming Healthcare, examined their hand-off communications problems, identified their specific causes for failures and barriers to improvement, and then identified, implemented and validated solutions that improved their performance.

Key Literature

Revisiting Readmissions-Changing Incentives for Shared Accountability. Epstein, AM, New England Journal of Medicine, 2009:360(14)1457-1459.

Transitions of Care Consensus Policy Statement. Snow V, Beck D, Budnitz T, et al. Journal of General Internal Medicine. 2009;24:971-976.

Patients and family members
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