Patient and Family Engagement - Tools and Resources
Effective patient and family engagement is dependent on structures and processes. Implementing or enhancing a patient and family engagement program should start with a gap analysis to examine how your organization is currently performing. The gap analysis provides insight into the needs for improvement. Patient and Family Engagement Gap Analysis (2-page Word doc)
Tools and Resources
Continuity Assessment Record and Evaluation (CARE) Tool Discharge. In 2008, Centers for Medicare & Medicaid Services (CMS) contracted to develop a comprehensive, standardized patient assessment tool for use at acute hospital discharge. The goal of which is to standardize patient information from post-acute care settings. (27-page PDF)
Discharge Preparation Checklist. A structured checklist of 10 critical activities a patient must be able to do to manage their care. (1-page PDF)
Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient. A guide for patients and families to use before leaving the hospital in an easy to use and update format. Developed by Consumers Advancing Patient Safety. (5-page PDF)
Your Discharge Planning Checklist. CMS developed a checklist that prompts patients and caregivers to ask questions about key discharge planning topics including their likely care needs, the options for continuing care, post-discharge care instructions, community-based resources, and more. (6-page PDF)
Asking Questions to Get the Care You Need. 3 minute video. May 2010. Agency for Healthcare Research and Quality, Rockville, MD. Video Advice Column from Dr. Carolyn Clancy, Navigating the Health Care System.
Taking Care of Myself: A Guide for When I Leave the Hospital. A guide for patients to help them care for themselves when they leave the hospital. The easy-to-read guide can be used by both hospital staff and patients during the discharge process and provides a way for patients to track their medication schedules, upcoming medical appointments, and important phone numbers.
Tips for Taking Medicines Safely. 3 minute video. May 2010. Agency for Healthcare Research and Quality, Rockville, MD. Video Advice Column from Dr. Carolyn Clancy, Navigating the Health Care System.
Transitions of Care Checklist. Provides a detailed list of topics to discuss prior to patient/clients/caregivers discharge to assess patient's care plans. Developed by the National Transitions of Care Coalition. (6-page PDF)
Care Transitions Program. Care transitions coaches support patients by providing specific tools and teaching self-management skills to ensure that patient's needs are met during the transition from the acute care setting to home.
- The Care Transitions Intervention. Eric Coleman, MD, director of the care transitions program at the University of Colorado in Denver, explains how to improve transitional care through engagement at the patient, provider, and health care institution levels. For each of these multiple levels, promising new innovations are featured. These include a transition specific self-care model that has been adopted by leading health care systems, new tools for detecting medication problems that arise during care transitions, and state-of-the-art performance measurement tools. The presentation concludes with a discussion of important developments in transitional care policy at the national level. (Recorded June 8, 2011) Part 1 (26-minute podcast), Part 2 (25-minute podcast) Handout (39-page PDF)
Project RED (Re-engineered Discharge). Standardized discharge intervention; includes patient education comprehensive discharge planning and post-discharge telephone reinforcement. Developed by the Boston University Medical Center.
Safe Transitions of Care Pilot by the Minnesota Hospital Association. Building on hospitals' ongoing work to reduce readmissions, MHA focused on improving patient safety by standardizing core elements of information during transitions of care between hospitals and across settings. MHA identified patient safety gaps due to transitions of care and core elements of information to close these gaps. Thirteen hospitals participated in MHA's pilot to incorporate the core elements into the discharge process. This webinar shares the lessons learned from the MHA safe transition pilot. (Recorded May 25, 2011) Part 1 (21-minute podcast), Part 2 (23-minute podcast) Handout (35-page PDF)
Limited English Proficiency
Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals. This guide focuses on how hospitals can better identify, report, monitor, and prevent medical errors in patients with limited English proficiency (LEP). Developed by The Disparities Solutions Center
TeamSTEPPS Enhancing Safety for Patients With Limited English Proficiency Module. This Agency for Healthcare Research and Quality (AHRQ) evidence-based training module will provide insight into the core concepts of teamwork as they are applied to your work with patients who have difficulty communicating in English. The toolkit includes an interpreter briefing exercise for patient discharge.
Promoting Effective Transitions of Care at Hospital Discharge: A Review of Key Issues for Hospitalists. Sunil Kripalani, Amy T. Jackson, Jeffrey L. Schnipper, and Eric A. Coleman. Journal of Hospital Medicine, Vol 2, No 5, Sept/Oct 2007.