The mission of the Texoma Care Transition Coalition is to enable safe and effective transitions of patients between all settings of care, and empowering patients and their families to manage their health.
- To improve the health of our community
- To reduce unnecessary hospital readmissions
- To be a vehicle for the patient and family voice
- To activate the patient's ability to self-manage their own health through person-centered and person-directed models of care
- To foster wise stewardship of limited community resources, reducing redundancy, and waste, and build and sustain a community coalition with a focus on improving transitions of care for Medicare beneficiaries
- To improve patient safety during transitions between health care settings
- To enhance the satisfaction of providers and staff through increased collaboration
- To collaborate and encourage efforts of organizations with shared visions and advance public policies that furthers the vision
Charter Member Commitments
- Share best practices and knowledge
- Mentor partners and providers
- Share data and support analyses
- Promote implementation of evidence-based interventions
- Healthcare Providers (Hospitals, Accountable Care Organizations (ACO), Skilled Nursing Facilities (SNF), Physician Practices, Home Health Agencies, Dialysis Facilities, Hospice Organizations, Palliative Care Organizations, etc.)
- Provider Associations
- Consumer Advocacy Organizations
- Government Organizations (Health Department, Area Agency on Aging, etc.)
- Quality Improvement Organizations
- Educational Organizations
- Funding Organizations
Coalition Participant Responsibility
Coalition Members agree to attend in person or by teleconference a minimum of fifty (50) percent of scheduled meetings each year with not more than two (2) consecutive unexcused absences.
Coalition Members agree to actively participate in committee work, and are expected to volunteer their services for Coalition projects.
Policies & Outcomes
No one may profit financially from membership in the Coalition by sales or solicitation at meetings or workshops. Participants will disclose any actual or potential conflicts of interest to QIO or other designee.
In the spirit of the Texoma Care Transition Coalition vision, all Coalition business shall be conducted based on the philosophy of mutual respect. Simple majority rules will apply. Coalition Participants are entitled to one vote per member.
Voting on the business of the Coalition may be conducted by those in attendance at the meeting either in person or by teleconference. Proxy voting via email is permissible.
- Improvements in Practice
- Implement improvements to the patient care continuum process and practices resulting in higher quality of patient care, improved access to programs and services, and reduced unnecessary hospital readmissions, thus resulting in reduced costs and improved patient satisfaction.
- Reduction of Readmission Rates
- Support our community’s hospitals in their efforts towards the partnership for patients goal of reducing hospital readmission rated by 20% within three years.
- Promotion of Best Practices
- Share best practices and knowledge and promote implementation of evidence based interventions.
- Improved Communication
- Improving communication between partners and providers by sharing data and support analysis with mutual respect for business-sensitive information.
ACH Clinical Record Review Tool
ACH is a good home health tool for looking at processes.
Assessment For Services HHA
Home Health Agencies Assessment for Services form.
Assessment For Services SNF
Skilled Nursing Facilities Assessment for Services form.
Audit Tool SNF-2
Audit Tool SNF is for SNF’s chart audits. You look at 5-10 readmit patient charts and look for trends as to why they returned.
Warning Signals for Congestive Heart Failure.
CMS Discharge Checklist
Your Discharge Planning Checklist.
Suggested Coaching Script, easing the transition from hospital to home.
Coaching Talking Points
Coaching talking points.
COPD Zone Tool
Self management plan for Chronic Obstruction Pulmonary Disease (COPD).
Discharge Risk Assessment
Discharge Risk Assessment (to be completed 2 days prior to discharge).
Health Literacy Tip Sheet
Health literacy tip sheet.
In-Patient Survey Data Collection Tool
Patient discharge survey.
HH Interview Guide
The Interview Guide is for root cause and is directed for home health staffing questions to look at staff perception.
Interview Guide SNF
The Interview Guide is for SNF’s root cause and is directed for SNF’s staffing questions to look at staff perception.
JT Audit Tool
JT Audit tool is for home health chart audits. You look at 5-10 readmit patient charts and look for trends as to why they returned.
Match Toolkit AHRQ 2012
Medications at Transitions and Clinical Handoffs (MATCH) for medication reconciliation.
Methods Process of Care Hospice
Methods Process of Care Hospice is an algorithm for hospice audits to look at the hospice processes.
PA Chart Review Audit Tool HH
PA Chart Review Audit Tool is geared more for hospitals. Choose which one works best.
Survey In-Patient Data Collection Tool
Survey in patient is a good tool to assess if a patient carried through on their discharge plans and to see if there was a problem.
Get started implementing the Care Transitions Intervention in your community.