Main Content


Care Coordination and Transitions Resource Center

Agenda and bios 

Indiana Healthcare Associated Infections Initiative Report 

  1. Knowledge Questionnaire Data
  2. 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


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 Stop and Watch Early Warning Tool

Resources / Toolkits

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