Care Transitions Workbook

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Community coalitions can be an effective way to engage diverse stakeholders in achieving common goals. Establishing such coalitions to address problems in care transitions is likely to be an essential tool for ensuring that such transitions become routinely good. Shortcomings in transitions today reflect larger, systemic problems that can best be addressed by community organizations working together. Indeed, no single organization will be able to resolve the broader issues, or work on its own to improve care transitions. It will truly take a village to make transitions safe, effective, and routine.

Many organizations around the country are looking to build coalitions that focus on care transitions. For many, similar experiences building community connections will enable them to establish and lead such coalitions. But many others will need guidance and support for learning the basics of coalition building, and for understanding issues specific to care transitions.

The Center for Eldercare and Advanced Illness posted a workbook, “It Takes a Village,” that offers  community leaders ideas and pointers for how to get started – and how to get going. It can be read in its entirety on the MediCaring.org website at: http://medicaring.org/action-guides/get-started

The guide provides an overview of coalition building, ranging from recruiting partners to resolving governance. It describes what to consider when setting priorities for the work. Much of the text is devoted to issues of measurement – how will coalitions know that their work is improving patient care and experience? The guide explains how to usemeasurement to advance the coalition’s goals, how to find good data sources, and how to decide on what to measure. It provides very specific information on fixing care transitions, including how to fix the hospital discharge process and how to target rehospitalizations. Because care transitions have a major effect on very sick and vulnerable patients and families, the guide also includes ideas for how coalitions can coordinate their efforts with palliative care programs and services.

Community coalitions have proven effective at addressing diverse public health issues, from improving maternal and child health to creating healthier environments. Coalitions are defined by their focus on a particular issue, by their willingness to collaborate, and by their ability to bring a range of resources and perspectives to problem-solving. The guide offers a starting point – we hope you find it compelling and useful.

We’d like to hear about your experiences – what works for you and what doesn’t, where are your successes and what have been your challenges. Please join the dialogue by offering comments here, or emailing us at info@medicaring.org. We look forward to hearing from you!

 

Key Words: care transitions, rehospitalization, readmission, quality improvement, coalition building, data sources, measurement

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