Transitions

SHM ACS Transitions Tool
This tool was developed by the SHM ACS Transitions Workgroup led by David Klocke in order to assure coordination of care throughout the hospital stay for patients with ACS. It is meant to serve providers caring for a patient with ACS from the ED to DC. Included in the tool are the key pieces of clinical information that need to be communicated and tracked throughout the hospital stay. Each of the core CMS measures and PQRI measures are included within the tool and can serve as part of the process to improve compliance with these quality measures.

There are two versions of the tool. The first version is designed for off the “off the shelf” use. It is for those teams that do not need additional customization to fit their institution. However, many institutions may have different needs or additional priorities. For these scenarios, we have included the easily modifiable version. The modifiable version is in Excel format so it can easily be used to capture data to allow automated monitoring.

View the formatted ACS Transitions Tool.

View the modifiable ACS Transitions Tool.

The Care Transitions Intervention
This is a web-based resource from the University of Colorado Health Sciences Center, Division of Health Care Policy and Research, regarding their Care Transitions Intervention. It includes many useful resources and tools, including:

• Protocol Manual: An Interdisciplinary Team Approach to Improving Transitions Across Sites of Geriatric Care.
• Discharge Preparation Checklist
• Personal Health Record
• Sample Transition Coach Charting Form
• Care Transitions Measure (CTM©)
• Medical Discrepancy Tool (MDT©)
• Links to some of the original Care Transitions Intervention reports:
• Coleman EA, Parry C, Chalmers S, Min SJ. The care transitions intervention: results of a randomized controlled trial. Arch Int Med 2006; 166:1822-8.
• Coleman EA, Mahoney E, Parry C. Assessing the quality of preparation for posthospital care from the patient's perspective: the care transitions measure. Med Care. 43:246-55, 2005
• Coleman EA, Smith JD, Frank JC, Min S-J, Parry C, Kramer AM. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc. 2004; 52:1817-1825.
• Smith JD, Coleman EA, Min SJ. A new tool for identifying discrepancies in postacute medications for community-dwelling older adults. Amer J Geriatr Pharmacotherapy. 2:141-7, 2004
• The Care Transitions Intervention: A Patient-Centered Approach to Facilitating Effective Transfers Between Sites of Geriatric Care.  Home Health Services Quarterly, 2003; 22:1-18.

SHM Inpatient Goal Sheet
This Inpatient Goal Sheet is a multi-disciplinary rounding tool to help to set daily goals for the hospitalized patient. This Goal Sheet was developed by the SHM Heart Failure Initiative Team Communications Workgroup. View Heart Failure Resource Room Project Team page for information on the workgroup members.

It may be useful for a variety of patients, and not only those with heart failure. The goal sheet creates an integrated home for team communication and addresses the myriad issues in preparing a patient for the discharge transition. It also serves as a reminder in case the patient is not progressing toward the identified goals, so that a re-assessment and review of the planned interventions can take place.
View the Inpatient Goal Sheet.

Sutter Medical Center, Sacramento, California, Patient Education Plan
The Sutter Medical Center website has made available ACS pre-printed orders and hospital forms via their website. These forms focus on the ACS core measures and include an Acute Coronary Syndrome Patient Education Plan.
View the Sutter Medical Center Patient Education Plan.