Care Coordination and Transitions Resource Center

• Improving Transition and Communication Between Acute Care and Long Term Care: A System for Better Continuity of Care - Annals of Long Term Care
• A Guide for Families: Making the Transition to Nursing Facility Life – American Health Care Association
• National Transitions of Care Coalition
• The Care Transitions Program®
• Care Coordination – Quality Connections, National Quality Forum
• Improving Care Transitions – HealthCare.Gov
• What is Care Coordination? – Agency for Healthcare Research and Quality
• Inter-Facility Infection Control Transfer Form – Centers for Disease Control and Prevention (State of Utah draft)
• Resident/Patient Continuum of Care Transfer Form – Georgia Cross Setting Group

Indiana Healthcare Leadership Conference on Care Coordination and Transitions

On October 27, 2011, the Indiana Department of Health conducted a Healthcare Leadership Conference for nursing home leadership, long term care provider associations, consumer advocate organizations, and state surveyors. The following are resources and tools provided at the conference:

• Agenda and bios
• Indiana Healthcare Associated Infections Initiative Report
  • Knowledge Questionnaire Data
  • Self-Assessment Data
• HAI Prevention and Antibiotic Stewardship Across Care Transitions
• A smooth hand-off – Getting Residents off to a Good Start
• Case Study:  Mr. McNally
• McNally Cards for Case Study
• Preferences for Customary Routine and Activities

INTERACT

• Overview of the INTERACT Program in Everyday Care
• INTERACT Care Path Acute Mental Status Change
• INTERACT Case Study 1 for QI Review
• INTERACT Deciding About Going to the Hospital
• INTERACT Hospital to Post-Acute Care Transfer Data List
• INTERACT Implementation Checklist
• INTERACT Nursing Home to Hospital Transfer Form
• INTERACT QI Tools
• INTERACT SBAR Form
• INTERACT Stop and Watch Early Warning Tool