Care Coordination & Transitions

Practical tools, playbooks, and workflows to ensure safe, timely transitions between care settings and reduce gaps in continuity.

playbook

Discharge Planning Playbook: Standardized Checklists, Medication Reconciliation & Follow-Up Workflow

A practical, adaptable playbook that organizes bedside checklists, a patient-centered medication reconciliation template, teach-back language, follow-up scheduling workflows, and post-discharge huddles. Designed so teams can adopt, tailor, integrate with EHRs, and measure impact to reduce readmissions and post-discharge problems.

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Workflow

Care Coordination Workflow Map & Role Matrix

A practical, end-to-end care coordination workflow with clear decision points, a role-and-responsibility matrix, ready-to-use SBAR-style handoff and referral templates, measurable KPIs, and implementation tips for technology and metrics integration—designed to reduce gaps in continuity, prevent avoidable readmissions, and make handoffs reliable and auditable.

Workflow
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Template Bundle

Discharge Standard Work Bundle for Complex Patients

A practical, ready-to-adapt bundle: a comprehensive discharge checklist (education, med list, equipment, home services), a step-by-step medication reconciliation process with a patient-facing verification script, a follow-up scheduling workflow and tracking template, clear escalation rules for social needs, role assignments, pilot guidance, and KPIs for measuring impact on readmissions and continuity of care.

Template Bundle
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Checklist Bundle

Discharge & Transitions Checklist Bundle

An interactive, editable bundle of practical checklists and templates that guide clinical teams through safer, more reliable discharges: discharge readiness, medication reconciliation, family education with teach-back, follow-up/referral scheduling, and an EHR-friendly handoff summary. Each checklist captures ownership, high-risk flags, notes, and a record that can be saved for follow-up, review, and continuous improvement.

Checklist Bundle
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playbook

Transitions for High‑Risk Populations: Discharge Bundles, Call Templates, and Escalation Protocols

Practical, cohort-specific discharge bundles and repeatable follow-up protocols for high-risk patients (heart failure, COPD, complex medication regimens). Includes ready-to-use checklists, phone-call scripts, community partner handoff items, escalation rules for missed follow-up, and measurement guidance with root-cause tagging.

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Workflow

Telephonic Post-Discharge Follow-Up Workflow for High‑Risk Patients

A practical, ready-to-adopt workflow and script for calling high-risk patients 48–72 hours after discharge. Includes pre-call preparation, a structured call script, a pragmatic risk checklist/score, clear escalation rules (same‑day clinic, home visit, ED referral), documentation fields, assignment rules, follow‑up scheduling, and a simple reporting template to measure impact.

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