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Improving Care Transitions Between Hospital and Home Health: A Home Health Model of Care Transitions

Resource Type: Toolkits
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This 71-page PDF outlines the Alliance for Home Health Quality and Innovation home health model for care transitions from hospital to home. The document includes an overview of the model; transitional care checklists to ensure essential elements are covered at important time points (e.g., patient education prior to hospital discharge); key components for care transitions tools (e.g., medication lists); transitional care guidance and guidelines; evidence-based tools; and patient resources. The model includes a COPD-specific "stop light" resource intended to enable those with COPD to identify exacerbation symptoms (i.e., COPD action plan). This tool will be most useful for the front-line COPD care provider.

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Citation: Alliance for Home Health Quality and Innovation. Published January 2014. Accessed July 17, 2018.
care coordination caregiver & community exacerbations hospitalization patient education patient experience post-acute care telehealth

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