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Quality Improvement:

IMPROVE YOUR OUTCOMES WITH THESE FREE TOOLS

Published on Thu Feb 12, 2009

Transition guides bring families onto your team.

If you're trying to improve transition planning, help families organize the patient's home care or create better communication to prevent unnecessary hospitalizations, check out the "Next Step in Care" Web site.

The site, launched by the United Hospital Fund, provides both a short and a long guide to home care services, under the heading "Next Steps." It discusses topics such as how to choose an agency, who pays for care and what is required to be sure the patient can be cared for at home safely. The site's resources address the most common transition challenges.

Example: When a patient is moving from the hospital or skilled nursing facility to home care, you can use the "Planner for Care at Home" -- available in English or Spanish -- to help the patient or family understand, organize and coordinate the many services the patient may need. The form collects contact information for the agency and its staff; organizes a list of supplies needed and where and how to get them; describes the services available; and includes a weekly care schedule form.

Resource: The guide "When Home Care Ends" (www.nextstepincare.org/uploads/File/NSIC_When_Home_Care_Ends.pdf) can help families understand the limits of home care and how to begin planning for the next transition.

Ace Medication Management

The site's medication management information combines a simple but effective form for the patient or family and information about what is involved in medication management. The form includes start and stop dates, information about required lab tests and side effects or danger signs. And a five-page instruction sheet tells providers how to prepare family caregivers to manage medications at home.

Don't miss: The hospital-to-home discharge guide walks the patient in detail through the steps needed to make a safe transition. It even includes information about how to appeal a hospital discharge decision. A similar guide is available for discharge to home from a rehab center.

Note: The "Next Step in Care" Web site is at www.nextstepincare.org.

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