Care Transitions Interventions/Tools 7 Steps to Managing Your Health: A Resource Guide Utilize this easy-to-use resource guide, 7 Steps to Managing Your Health, in order to take a more active role in your own healthcare. When you take an active role, it is more likely that you will stay healthier. The guide provides tips and a list of useful resources with an emphasis on Burlington and Camden Counties. Change Packages/Intervention Matrix Change Packages introduce the following eight categories of potential interventions: Patient/Family Education, Advance Care Planning, Multidisciplinary Staff Education, Discharge Planning, Physician and Cross-provider Education, Patient/Family-centered Handover Communication, Quality Improvement, and Facility-chosen Interventions. While some potential Interventions (Advance Care Planning, Patient and Family Education) are used across all healthcare settings, others (Disease Management, Fall Prevention) are applicable only under selected circumstances. This grid identifies 13 potential Interventions and the settings in which they might be employed. The Centers for Medicare & Medicaid Services (CMS) has created a checklist for patients preparing to leave a hospital, nursing home, or other healthcare facility. Designed to be used by patients, family members, and caregivers, this checklist helps simplify what can be an overwhelming experience. INTERACT - Interventions To Reduce Acute Care Transfer in the Care Transitions The INTERACT II Program is designed to improve the quality of nursing home care by providing staff with tools and resources that will help to reduce avoidable acute care transfers.
Use these tools to improve communication between caregivers in nursing homes and healthcare providers outside the nursing home, as a resource to guide the nursing staff through a comprehensive assessment when there is an acute change in condition, and to equip your staff with the necessary skills to start and respond to conversations about palliative and end-of-life care. Learn when to use the SBAR — Situation-Background-Assessment-Recommendation — Communication Tool and Progress Note and who to involve in the process, and also find an assortment of helpful hints. The purpose of SBAR is to improve communication between nurses and primary care providers by encouraging all healthcare team members to use the same language when communicating with one another. Personal Health Record (PHR) While deceptively simple, PHRs can make a tremendous difference. A summary of a patient’s overall health, it includes a comprehensive list of medications. The very act of compiling PHRs gives patients a deeper understanding of their own health, allowing them to make informed decisions. This PHR, with large easy-to-read print, was designed especially for use by older adults. Typically, the medical records section is printed on bright green paper, while the medication section is printed on red. The booklet is folded, not stapled, allowing the insertion of updated information. | 
