Resources

Use the CTEP Resource Guide to find other useful information , including a Glossary of Terms related to care transitions, and web links to many care transitions-related readings, websites, organizations, and initiatives.

• CTEP Summary
• CTEP Pilot Evaluation
• CTEP Statewide Kickoff Presentation
• CTEP Presentation Poster
• CTEP Resource Guide
• All Curriculum Downloads

Contact CTEP to learn more about access to training and/or technical assistance.

Additional Resources

• INTERACT II – Interventions to Reduce Acute Care Transfers

  Quality improvement program focused on management of acute change in nursing home resident condition. (in use by 30 nursing home care teams in Massachusetts, NY and FL).

• Massachusetts Expert Panel on End-of-Life Care Report (2010)

  Provides context, overview of current status, framework and recommendations for improving end-of-life care in Massachusetts.

• Massachusetts Patient-Centered Medical Homes Initiative (2011)

  EOHHS initiative; service delivery model of care coordination and improved access to care by 2015.

• Massachusetts Strategic Plan for Improving Care Transitions

  Overview of care transition issues, principles and recommendations for improvement in Massachusetts.

• Massachusetts Nurse of the Future competencies

  Framework for nursing curricula – including nursing competencies related to patient care transitions.

• Massachusetts MOLST (Medical Orders for Life-Sustaining Treatment) (available statewide by 2013)

  Medical process and form to establish and honor medical orders for life-sustaining treatments across care settings for individuals nearing the end of life.

• Project RED (Reengineering Discharge)

  A research group at Boston University Medical Centerthat develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates

• STAAR (STate Action on Avoidable Rehospitalizations Initiative)

  Initiative to improve quality, patient experience and reduce avoidable hospital readmissions (20+ hospitals in MA; (also in MI and WI). Led by Institute of Healthcare Improvement.

• Western Massachusetts Nursing Collaborative forum: Achieving Successful Transitions Along the Continuum of Patient Care

  Notes and materials from a December 2010 symposium re: care transitions focused on nurses.