Care Transitions

These resources focus on quality improvement for care transitions. The current required and additional Medicare Beneficiary Quality Improvement Project (MBQIP) measures that fall under this domain are:

  • Emergency Department Transfer Communication
  • Discharge Planning
  • Medication Reconciliation

For more information about the reporting requirements for these measures, see Data Reporting and Use.

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Quality Improvement Toolkit for the EDTC Measure

This toolkit includes an overview of the quality improvement process and how it can be applied, as well as tools and resources that can be adapted to support the transfer of critical patient information from the ED to other care settings. 
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Preventing Avoidable Readmissions

The Preventing Avoidable Readmissions website offers information and tools for clinicians and patients to make the hospital discharge process safer and to prevent avoidable readmissions.
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Re-Engineered Discharge (RED) Toolkit

The Re-Engineered Discharge (RED) Toolkit was developed to help reduce readmissions and post-hospital emergency department (ED) visits. This toolkit is designed to assist hospitals, particularly those that serve diverse populations, to replicate RED.
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Always Use Teach-back! Training Toolkit

The purpose of this interactive toolkit is to help all health care providers learn to use teach-back to support patients and families throughout the care continuum, especially during transitions between settings.

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MATCH Toolkit for Medication Reconciliation

MATCH toolkit for Medication Reconciliation incorporates the experiences and lessons learned by health care facilities that have implemented MATCH strategies to improve their medication reconciliation processes for patients as they move through health care settings.

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,100,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.