Knowledge & Resource Center

Welcome to the Knowledge & Resource Center, a collection of transitions of care tools that seek to improve care transitions and positively impact health outcomes. 

The Center features tools and resources submitted to the Essential Resource Program, which address a specific transition of care issue; assist patients, caregivers, healthcare providers and others with respect to transitions of care; and/or positively impact patient outcomes. Submitted tools and resources must also address one or more of the NTOCC Seven Principles, principles by which providers and organizations must adhere to improve transitions of care, as well as the NTOCC Seven Critical Interventions, key elements found in evidence-based care interventions. We hope you find the following tools and information useful: 

  • PRIME® Education


    Despite significant treatment advances, new evidence, and recently updated guidelines, high rates of hospital readmissions and poor outcomes persist for patients with heart failure. Experts recognize the remarkable potential to reduce unnecessary hospitalizations and improve patient outcomes through effective interventions at critical transition points to bridge gaps in care. Developed in partnership with the National Transitions of Care Coalition (NTOCC) and led by a multidisciplinary advisory board, this Heart Failure Transitions of Care (TOC) pathway provides essential interventions and tools to support system leaders and the interprofessional care team - including patients and their caregivers - in incorporating the latest evidence-based treatment and management approaches to ensure effective and safe transitions of care for patients with heart failure across healthcare settings.

  • JANSSEN CONNECT® is an information and assistance program designed to help patients start and stay on their Janssen long-acting injectable atypical antipsychotic after their healthcare professional has deemed it to be the most clinically appropriate treatment option. 

  • Care4Today® Mobile Health Manager is a free mobile app designed to support and motivate people to stay on schedule with their medications. Care4Today® Mobile Health Manager includes an up-to-date database containing 40,000 FDA-approved medications and 20,000 images inclusive of generic and brand name medications. 

  • PAH White Paper is a transitions of care white paper that was developed by NTOCC and Case Management Society of America (CMSA) for system leaders and interprofessional clinical team members who treat and manage patients with PAH. 

  • The Joint Commission's Transitions of Care Portal is a valuable source of information from The Joint Commission enterprise and other healthcare organizations, related to the topic of transitions of care (the movement of patients between various health care settings.)
  • IPF White Paper is a transitions of care white paper that incorporates essential interventions and tools designed to ensure effective and safe transitions of care for patients with IPF across healthcare settings.
  • Improving DVT/PE Transitions of Care, offered by Janssen and Johnson & Johnson through their CarePath|Healthy Engagements program, is a resource designed to help prescribers, care coordinators, nurses, and other healthcare professionals facilitate the transition of care for patients being discharged from the hospital after a deep vein thrombosis (DVT) or pulmonary embolism (PE) diagnosis.
  • The Diabetes Transitions of Care Kit, offered by Janssen and Johnson & Johnson through their CarePath|Healthy Engagements Program,
    provides tools and resources for providers/staff members who support care transitions for patients with Type 2 Diabetes (T2D) and multiple chronic conditions in hospitals/health systems.