Healthcare Professionals
Healthcare professionals strive every day to provide patients with the most effective, safe and beneficial care possible. The healthcare industry works hard to create the best care delivery within each practice setting and area of responsibility. However, it is when patients transition between these settings that dangerous situations may arise — not through any fault of the professionals involved, but because the system is very complex with no clearly defined specific responsibilities for effective patient hand-offs.
NTOCC has brought together thought leaders and representatives of different practice and professional settings to study the transitional challenges and identifying tools which can help improve Transitions of Care. Working together we can reduce transitional problems and ensure patient safety.
Available Tools & Resources
NTOCC has created information to help healthcare professionals understand how poor transitions impact care delivery and how you can help improve transitions in your facility.
Join NTOCC as an individual subscriber or ask for your company to join as an Associate Member to be notified as new tools become available.
NTOCC UPDATED CARE TRANSITION BUNDLE 2022
In 2022 NTOCC Made significant changes to the Care transitions Bundle 7 Elements to successful transitions of care. You can downlad the bundle and definitions below.
NTOCC Care Transition Bundle 2022
NTOCC Care Transition Bundle Definitions 2022
PHARMACY TOOLS
“KNOW YOUR PHARMACIST”
In 2022 the Transitions of Care Pharmacists Advisory Committee released its Transitions of Care Pharmacists 10 Principles. The interaction with the NTOCC community showed that many healthcare professionals were not aware of the significant role and scope of practice pharmacists have in not only transitions of care but in supporting care coordination. Pharmacists offer an array of services through the implementation of Medication Management Services (MMS). Download the “Know Your Pharmacist” tool here
Transitions of Care Pharmacists
10 Principles
The National Transitions of Care Coalition (NTOCC) convened a Transitions of Care Pharmacy Task Force that is committed to education, resources, tools, developing public and professional awareness, and partnership with like-minded organizations to acknowledge the essential role that pharmacists have – in operating at the top of their license – in transitions of care and care coordination.
click below for the 10 principles
We the Task Force members have committed to the following principles:
heart failure tools
Multi-Stakeholder Summit Heart Failure Empowerment tool
The National Transitions of Care Coalition in collaboration with our partners from the Multi-Stakeholder Summit have launch the Patient Empowerment Tool "Taking Control of Your Heart Failure: Life After a Heart Failure Hospitalization".
The Patient Empowerment Tool is designed for Heart Failure patients. It highlights several key rights patients should know and offers high level guidance to support self-care management and empowerment upon hospital discharge. Supporting greater patient engagement is an important intervention for improving transitions and care coordination across the continuum of care. It is important that patients and their family caregivers understand that treating their heart failure doesn't end after leaving the hospital. The goal of the Patient Empowerment Tool is to support patients in becoming an "empowered" patient and create a stronger partnership with their health care team and heart failure provider. We have also included the addendum and support document, "COVID-19 Frequently Asked Questions for Person with Heart Failure". Both documents can be found within the links below.
Taking Control of Your Heart Failure: Life After a Heart Failure Hospitalization
COVID-19 Frequently Asked Questions for Person with Heart Failure
Heart Failure Charter
The Heart Failure Charter is call-to-action to reduce preventable heart failure hospitalizations and improve patient outcomes. The Multi-stakeholder Summit was convened by Novartis Patient Advocacy with the goal of bringing together patient and caregiver advocacy groups and professional societies to better understand the burden of HF hospitalizations and transitions of care across patient touchpoints.
COVID-19 HEALTH MANAGEMENT
NTOCC is excited to share a new consumer tool and resource. “COVID-19 Health Management”. This resource can assist consumers in talking to their health care professionals about issues and concerns they may have if exposed to or having symptoms related to COVID-19.
My Medicine List
This form helps you gather important information about your medications. Filling out this list prior to visiting your doctor or entering the hospital will help ensure your healthcare providers know what medications you are already taking. When your doctor writes you a new prescription or changes your medication ask them to update your My Medicine List. Working with your doctors to fill out the form will help you better understand what medications you should be taking.
Patient Bill of Rights During Transitions of Care
Transitions of Care (or care transitions) take place each time you go from one healthcare provider or healthcare setting to another. Problems often happen during these transitions because information is not communicated. You and your family have the right to care transitions that are safe and well coordinated. This guide can help you get the information and services you need and deserve each step of the way.
Taking Care of My Health Care
Taking Care of MY Health Care has been a much anticipated consumer tool. The tool was developed by the NTOCC Tools and Resources Work Group. It has been through numerous reviews with the group, by social workers, and a literacy review. The NTOCC Advisory Task Force approved it on September 16, 2008 at their meeting in Washington DC. This tool was developed as a guide for patients and their caregivers to use so they can be better prepared when they see a health care professional on what kind of information and questions they need to ask. NTOCC’s goal was to keep it simple; as a guide, to open the lines of communication and to provide them with a convenient, simple format to have an updated list of their medication and what the next step in their care would be.
Informational Slide Deck
View this presentation to learn more about how Transitions of Care impacts your safety and how NTOCC is working to ensure improved transitions for you and your family.
Informational Brochure
This brochure contains easy to understand information about transitions of care that can help you in sharing and discussing this critical health care issue.
How to Implement & Evaluate a Plan
This Implementation Plan, along with the Executive Summary and individual modules, provides an outline of the concepts, process and "how to" on implementing and evaluating a Transitions of Care plan. In using the guidebook each transition point is treated as an exchange. Each exchange is where communication occurs and where evaluation may occur.
Download the Executive Summary
Transitions of Care Measures
At present, there is a large evidence base that demonstrates the existence of serious quality problems for patients undergoing transitions across sites of care. While currently there are transitions of care measures on the structure, process, and outcomes of care that are useful, measure gaps still exist. This report by the NTOCC Measures Work Group summarizes an environmental scan of existing measures that are applicable to care transitions and highlights the Work Group's recommendations. Included is the Care coordination Hub, a conceptual model defining seven key elements for effective transitions of care.
Included is the Care Coordination Hub, a conceptual model defining seven key elements for effective transitions of care.
Transitions of Care Checklist
This list provides a detailed description of effective patient transfer between practice settings. Implementing this process developed by NTOCC can help to ensure that patients and their critical medical information are transferred safely, timely, and efficiently.
Cultural Competence: Essential Ingredient for Successful Transitions of Care
Healthcare professionals increasingly recognize the crucial role that culture plays in the healthcare of a client or patient and the need to deliver services in a culturally competent manner. Cultural competence is essential to successful, client-/patient-centered Transitions of Care. This tool provides information about culture and cultural competence, as well as strategies and resources to enhance professionals’ capacity to deliver culturally competent services during Transitions of Care.
Improving Transitions of Care with Health Information Technology
NTOCC believes that for Health Information Technology (HIT) to make a difference in Transitions of Care, the technology must address several critical steps, including standardized processes, good communication, required performance measures, established accountability, and strong care coordination. Without addressing each step, the promise of HIT’s affect on overall transition of care improvement will not be realized.
Because there is little guidance on how to use HIT in ways that specifically improve Transitions of Care, this paper builds upon NTOCC’s overall recommendations for improving Transitions of Care and the national agenda as it relates to HIT, and identifies problems and considerations as they relate to NTOCC’s overall goals.
Medication Reconciliation Essential Data Specifications
These consensus elements will help healthcare professionals collect, transmit and receive critical medication information needed when patients move from one practice setting or level of care to another. The use of these elements in the reconciliation process required by the Joint Commission could help reduce medication errors.
Issue Briefs: Improving Transitions of Care
This issue brief organizes the findings and considerations of the vision of the National Transitions of Care Coalition.
Policy Paper
This detailed concept paper outlines steps to be considered by the health care industry and policy makers to improve transition performance.