Care Transitions

Improving Community-Based Care Transitions

Improving care transitions will help prevent medical errors, reduce unplanned hospital utilization, and increase the overall quality of care in the community.

We connect health care organizations with community-based organizations to identify community-specific needs and opportunities, share best practices, and support interventions that enhance the overall health of your community.

Coalitions explore opportunities to enhance patient and family engagement, better leverage health information technology, reduce health inequities, and address social determinants of health.

We will work with you free of charge to implement evidence-based interventions and best practices that target your specific needs and identify measurement strategies that are feasible and allow you to track improvement in your organization and community.


  • Reduce hospital admissions and readmissions
  • Decrease community-based adverse drug events (ADEs)
  • Understand and address the unique needs of super utilizers
  • Monitor access-to-care issues that may result in increased hospital utilization
Improving Care Transitions

Clinical and Quality Improvement Offerings

Technical Assistance

  • Facilitate and support interpretation of community-based root cause analyses
  • Support evidence-based and best practice intervention selection
  • Identify meaningful and feasible measurement strategies
  • Evaluate effectiveness of interventions and support innovative strategies that sustain goals

Tools and Education

  • On-demand, web-based education from recognized experts
  • Connection with peer providers for shared learning
  • Benchmarking and feedback data reports for comparative analysis
  • Educational resources for clinicians, staff, patients, and residents to support enhanced care coordination

Highlighted Tools and Resources

Addressing Drivers

  • Information Transfer
  • Patient and Family Activation
  • Standard and Known Care Processes
  • Trauma Informed Care
  • Social Determinants of Health
  • Medication Reconciliation
  • Substance Use
  • Access to Care

Evidence-Based Models

  • Care Transitions Intervention (CTI)
  • Project BOOST
  • Project RED
  • Transitional Care

Best Practices

  • Connecting with Community Resources
  • Engaging Caregivers
  • Practicing Teachback
  • Screening for Social Determinants of Health

For Questions or Support

Looking for more information? Check out our fact sheet to learn about our Care Transitions initiative.