Websites on care transitions:

• United Hospital Fund. Next Step in Care: Family Caregivers & Health Care Professionals Working Together
• ABIM Foundation. Stepping Up to the Plate: Alliance to Improve Care Transitions
• American College of Physicians. Patient Centered Medical Home
• Centers for Medicare and Medicaid Services. Medicare QIO Care Transitions Project
• The Commonwealth Fund. Quality Matters: Care Coordination
• Health Information Exchange in Post-Acute and Long-Term Care: Final Report
• Institute for Healthcare Improvement. Transforming Care at the Bedside How-to Guide: Creating an Ideal Transition Home for Patients with Heart Failure
• The Joint Commission. Speak Up: Planning Your Follow-up Care
• Medicare Payment Advisory Commission (MedPAC). Report to the Congress: Reforming the Delivery System
• National Alliance for Caregiving and United Hospital Fund of New York. A Family Caregiver’s Guide to Hospital Discharge Planning
• Society of Hospital Medicine. Better Outcomes for Older Adults through Safe Transitions (BOOST)

Related projects funded by the John A. Hartford Foundation:

• Intermountain Healthcare: Care Management Plus
• PeaceHealth, Oregon Region: Senior Health Clinic Outcome Study
• Rush University Medical Center: Virtual Integrated Practice


For an overview of these projects, please see
• John A. Hartford Geriatric Interdisciplinary Teams in Practice
• Models of Geriatric Care

Additional Resources:

• The Practice Change Leaders for Aging and Health
• The National Quality Forum
• The Society of Hospital Medicine
• Quality Improvement Organizations – listing and links, organized by state
• The Institute for Healthcare Improvement
• The National Transitions of Care Coalition
• Strategies to Engage Physicians CFMC Integrating Care

The Care Transitions Intervention^® and all of its materials are the property of the Care Transitions Program^®. The Care Transitions Program^® is solely authorized to provide training on the Care Transitions Intervention^®. If another entity offers to train your organization, please contact us.

© Eric A. Coleman, MD, MPH