National Care Transitions Awareness Day is this week We know that effective transitions of care within and from the hospital setting are a key driver for improvement in readmissions. As a matter of fact, CMS guidance for discharge planning maintains that every hospitalized patient requires safe and effective care transitions practices, with planning for that transition starting at the time of admission.

The Whole Person Care Transitional Planning Tool, part of the ASPIRE Hospital Guide to Designing and Delivering Whole Person Transitional Care from the Agency for Healthcare Research and Quality (AHRQ) is intended to help hospital-based readmission reduction teams design and deliver transitional care to address “whole-person needs”. This approach to transitional care is intended to help hospitals adapt strategies to better meet the clinical, behavioral, and social transitional care needs of patients prior to a transition to another level of care. The tool can be modified and used as a method for communication between levels of care, care providers, or other healthcare organizations as part of a larger effort to reduce readmissions.

What method are you using for effectively communicating your patient’s “whole person needs” to the next provider of care during handover transitions?