Resources for Addressing Social Barriers to Transitions

These new standardized instructions to improve patients' understanding of when to take medications, reduce errors and improve adherence are available in six languages.

This guide, provided by the Institute for Healthcare Improvement, is designed to support hospital-based teams and their community partners in code signing and reliably implementing improved care processed to ensure that patients who have been discharged from the hospital have an ideal transition to the next setting of care.

This how-to guide is designed to support hospital-based teams and their community partners in creating an ideal reception in home health in the first 48 hours after the patient is discharged from the hospital, a post-acute care setting or a rehabilitation facility.

Patients are more at risk for experiencing gaps in care that lead to rehospitalization during the transition between care settings. The focus of this guide is the transition of residents from hospital to the skilled nursing facility (SNF) setting and the associated transfer of responsibility from the hospital to the SNF care team.

This guide focuses on the reception of patients back into the office practice after hospitalization. Patients are especially vulnerable to adverse events in the period immediately following discharge, and they need immediate access to a trusted clinician who can answer questions, provide advice, and help ensure that their clinical conditions remains stable.

The Medications at Transitions and Clinical Handoffs (MATCH) toolkit was developed to help facilities improve their medication reconciliation process. This toolkit provides a step-by-step guide to help health care providers ensure patients are properly educated about the medications they have been prescribed to help avoid medication errors and patient harm.

Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.

The Agency for Healthcare Research and Quality, in coordination with Boston University Medical Center, has developed an online Re-Engineered Discharge (RED) tool kit. RED has been shown to be effective in reducing readmissions and post-hospital emergency department visits.

Internists/primary care physicians and nurses: Provide this document to your patients, which includes more information to help them ascertain when to call your office for help or when to go to the emergency room for a range of conditions, including shortness of breath, heart failure, complications with diabetes and more. Patients: Use this document to help determine when to call your physician for help or when to go to the emergency department for assistance.