Web Links and Articles

Web Links

  • Integrating Care for Populations and Communities National Coordinating Center

    The National Coordinating Center for Care Transitions helps Quality Improvement Organizations across the country to promote seamless transitions between healthcare settings.

  • Engaging Physicians in Improving Care Transitions and Recuing Readmissions

    Physicians can be critically important allies in efforts to lead, facilitate, and participate in a range of activities and practice changes that will improve care, optimize communication during transitions of care, and reduce avoidable readmissions. This guide provides you with insights and varied approaches to use when engaging physicians.

  • National Transitions of Care Coalition (NTOCC)

    Founded in 2006 by the Case Management Society of America, the NTOCC is a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care: the movement of patients from one practice setting to another.

  • Partnership for Patients

    The Partnership for Patients: Better Care, Lower Costs is a new public-private partnership that will help improve the quality, safety and affordability of health care for all Americans.

  • MedActionPlan

    Use this discharge planning tool to advance patient safety, patient education, and adherence to medication therapy.


The following articles provide an opportunity to gain a broader depth of knowledge of care transitions.

The Institute for Healthcare Improvements’ (IHI) Meta-Analysis of Effective Interventions to Reduce Readmissions:
An IHI PubMed search of the published literature to find evidence of the most effective interventions to improve transitions of care and reduce rehospitalizations

Improving Care Transitions—Optimizing Medication Reconciliation:
The American Pharmacists Association (APhA) and the American Society of Health-System Pharmacists (ASHP) recently released Improving Care Transitions: Optimizing Medication Reconciliation. The white paper provides a better understanding of the medication reconciliation process during transitions in care, its effect on patient care and outcomes, and how pharmacists can contribute to the improvement of this process through medication therapy management.

Integrated Care Cuts Hospital Admissions by a Fifth:
Integrated care can cut hospital admissions for elderly patients by at least one-fifth, according to a new report from RAND Europe, Ernst & Young, University of Cambridge and the Nuffield Trust.

Hospital Checklists Cut Readmissions, Medicare Costs:
In another win for in-hospital checklists, new research finds that a simple, one-page checklist can keep heart patients out of the hospital, as well as save Medicare billions of dollars, according to a presentation given at the American College of Cardiology's (ACC) annual scientific session.

Affordable Care Act Update: Implementing Medicare Cost Savings:
The Affordable Care Act reforms the Medicare program's payment and delivery systems to help drive system-wide cost savings and quality improvement. Cost-containment strategies resulting in 10-year projected savings are included in the article.

Hospital Readmission Among Participants in a Transitional Case Management Program:
The following article describes a study on the implementation of a telephonic transitional case management program (TCM) designed for patients discharged from an acute care facility. Results indicate an effective reduction in hospital readmissions.

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey:
Medicare beneficiaries rate discharge planning as the greatest dissatisfaction score. This document is the actual HCAHPS survey, which defines survey questions. Note: questions 18, 19, and 20 as they relate to care transitions.

Effective Interventions to Reduce Rehospitalizations: A Compendium of 15 Promising Interventions:
A review of 15 promising interventions to reduce hospital readmissions. The article includes evidence-based effectiveness and rehospitalization results, identifies issues of complexity, and illustrates cost benefits.

Hospital Readmissions Reduction Program
HealthReformGPS provides an overview and suggested items to monitor the Affordable Care Act. Categories of interest include definitions of readmissions, calculation of payment, and risk factors.

Rehospitalization Among Patients in the Medicare Fee-for-Services Program
This research methodology analyzes data from Medicare claims and patterns of rehospitalization. The authors provide a study of the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals.

Preventing Hospital Readmissions: a $25 Billion Opportunity
This compact action brief by National Priorities Partnership provides a roadmap to identify opportunities to address readmissions, corresponding solutions, and drivers for change.

Health IT Tools Reduce Readmissions at Philadelphia Hospitals
This 18-month project reduced readmissions in 18 Philadelphia hospitals using electronic health records (EHRs). Results indicate a savings of $4 million for the third quarter of 2011.

Lessons from Medicare's Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment
This Congressional Budget Office article reviews outcomes of six disease management and care coordination demonstrations and four value-based purchasing demonstrations and recommendations for consideration to increase savings.

Family of Woman Who Died After a Medical Error Joins Hospital's Safety Panel
A young woman dies from a medical error at a hospital. The family joins the Advisory Council of a Chicago hospital in an effort to improve patient safety.