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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Checklist Bundle

Discharge & Transitions Checklist Bundle

A set of standardized checklists for safe discharge planning, medication reconciliation, family education, and follow-up coordination.

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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